Professional Documents
Culture Documents
RELEASE
ThERAPY
Assessmenr&r;-eannenr
Dys/unction
of Musculoskeletal
POSITIONALRELEASE
T
Assessment&freatment of
APY Musculoskeletal Dysfunction
iHER
1George B. Roth, B.Se., D.C., N.D.
Continuing Education
Hartford, Connecricucj
Toronto, Canada;
Caledon, Canada;
wid... illustrations by
with phocographs by
] eanne Robertson
Stuart Hal/Jerin
an d
Matthew Wiley
T
SI lOUIS
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IDNLM: I. Manipulation, Orthopedic-methods.
2. Pain-therapy.
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Dedication
The authors would like to dedicate this book to Dr. Lawrence Jones, D.O., FA.A.O.
(1912-1996) for his pioneering discoveries in the field of musculoskeletal treatment and
his contributions to the service of mankind. Dr. Jones spent over 40 years developing
StrainCounterstrain. During the process he gave his time, energy, and talent so that
future generations of practitioners could enhance the care of their pariencs. His contribu..
tions have gained the respect and admiration of a broad spectrum of health professionals
worldwide. Dr. Jones made it his life's work to share his knowledge for the benefit of
others. We hope that our contribution [Q this continuing work will do his memory justice.
vi
Forewords
the same thing to the same thing, no maner what they say
lungs, the brain and spinal fluid, the gut, kidneys, liver, and
is both a "how to" manual and a "why for" text. The mar
Vienna, Virginia
vii
viii
FOREWORDS
Acknowledgments
this book.
who are
M>
Most of all, I'd like to thank Illy loving wife Jane and Illy
family, who have provided me with the love and support
Kerry J. D'Amhrogio
P.T., and
George B. RDlh
ix
ACKNOWlEOOMENTS
R.M.T., and Robin Whale, D.C., for the long hours they
Preface
xii
PREFACE
past several years and found that our paths were inter'
quem treatments.
terstrain (the latter being the title of his orginal text). Sev
the stu..
[Q
PREFACE
XIII
Contents
Chapter 1
19
27
35
39
22I
227
231
251
xv
POSITIONAL
RELEASE
ThERAPY
Assessmen t&frealmenf
of Musc,.loskeletal D,sfunction
1
Origins of Positional
Release Therapy
Body Positioning
Tender Points
Indirect Technique
History of Counterstrain
Recent Advances
Summary
, BODY POSITIONING
Body posture and the relative position of body partS has
Fig. I-I
Yoga pos(!(res. A,
Bow. B, Plough.
'References 1,7.9,10,11,15,17.
CHAPTER I
Fig. 1-2
The
'TENDER POINTS
Acupuncture points have been used therapeutically for at
least 5000 years. TI1CSC points correlate closely with many of
those "discovered" by subsequent investigators (Fig. 1-3).36
References in the western literature to the presence of pal;
pable tender points (TPs) within muscle date back to 1843.
Froriep described his so-called Muskelschwiele, or muscle
callus, which referred to the tender points in muscle that
were found to be associated with rheumatic conditions. In
1876 the Swedish investigatOr Helleday described tender
points and nodules in cases of chronic myositis. In 1904
Gowers introduced the term fibrositis to describe the pal
pable nodule, which he felt was as ociated with the fibrous
elements of the musculoskeletal system. Postmortem studies
by Schade, which were reported in Germany in 1919,
demonstrated thickened nodules in muscle, which served to
confirm that these histOlogic changes evolved into lesions
that were independent of ongoing proximal neurologic
excitation.]] In the 1930s Chapman' discovered a system of
, INDIRECT TECHNIQUE
The histOry of therapeutic intervention to affect
structures can be broadly divided into direct and indi#
reet techniques. Direct techniques involve force being
applied against a resistance barrier, such as stretching, joint
mobilization, and muscle energy.S,lO Indirect techniques
employ the application of (orce away from a resistance
barrier, that is, in the direction of greatest ease. Indirect
therapies, including PRT, have evolved in various forms
and share cerrain common characteristics and under
lying principles.
In 1943 Sutherland" introduced the concept of manip
ulation of cranial StrUCtures. His technique to treat cra-
//'
( AJ
K27
----;---_.
;; '
6110
6111
-+---jH
619
6147
6148
6149
'
6150
'J
K10
618
61 23
61 25
CflAPTER
---..
_ 61 53
61 54
6160
K3
fig. I]
61 67
Acupullcture lJOim5 related [0 A, the kidney meridian; and B, rhe blMder meridian.
CHAPTER I
Fig. 1-4
Chapman s reflexes.
I
Vt, 1988.
Healing Aru
Press.)
.The patient was then slowly taken out of the position and
patient and Jones. the patient stood erect and with drasti,
, HISTORY Of (OUNTERSTRAIN
were
assoc
, RECENT ADVANCES
Positional release therapy owes its recent evolution to a
number of clinicians and researchers. SchwartzI9 adapted
several techniques to reduce practitioner strain. Shiowitz28
introduced the use of a facilitating force (compression, tor;
sian, etc.) [Q enhance the effect of the positioning. Ramirez
and othersll discovered a group of tender points on the pos;
terior aspect of the sacrum that have significant connec
tions [Q the pelvic mechanism. Weiselfish34 outlined the
specific application of positional release techniques for use
with the neurologic patient. She found that the initial
phase of release (neuromuscular) required a minimum of 3
minutes, and she also outlined protocols to locate key areas
of involvement with this patient population. She, along
with one of us (O'Ambrogio), outlined the twO phases of
release: neuromuscular and myofascial. Brownl developed a
system of exercise for the spine in which a painfree range
of motion is maintained. One of us (D'Ambrogio) devel
oped the scanning evaluation procedure to facilitate the effj
ciency and thoroughness of patient assessment,6 and one of
us (Roth) has developed improved practitioner body
mechanics to reduce strain and has correlated lesions with
CHAPTER I
, SUMMARY
Positional release therapy has historical roots in antiquity.
The three major characteristics (body positioning, the use
of tender points, and the indirect nature of the therapy) can
be individually traced to practices established over the past
5000 years. Connections can be made with the ancient dis
ciplines of yoga and acupuncture and with the work of
investigators over the course of the past twO centuries. The
correlation of different systems that use tender points sug
gesrs a common mechanism for the development of these
lesions. Significant contributions to the development of
this art and science have been made by Jones121J.16 and
others. Positional release therapy is being continually
advanced and developed through the contributions of many
clinicians and researchers.
References
I.
2.
3.
4.
5.
6.
7.
8.
9.
10.
I!.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Res ),79,1984.
Chaitow L: Sofllimu! manipulation. Rochester, Vl, 1988. Healing
Arts Press.
ChaitOw L: The acupunclUre rreannem of pain, Wellingborough,
1976,Thorsons.
Chapman F. Owens C: Introduction 10 and endocrine inteT1Jreuwon of
Chapman's reflexes. self-published.
O'Ambrogio K: Strain/counterstrain (course syllabus), Palm Beach
Gardens, 1992,Upledger Insmure.
Fcldcnkmis M: Awareness through I7lOt.IeTlltn!: health exercises fCJr pe T
sonaigrowlh, New York, 1972, Harper & Row.
Greenman PE: Principles of manual m.edicine. Baltimore. 1989.
Williams & Wilkins.
HashImoto K: SOlai natural exercise, Oroville, Calif, 1981. George
Ohsawa Macrobiotic Foundation.
Hewitl J: The compiele yoga book , New York, 1977,Random House.
Hoover HV: Funcrionallechnic, AAO Year Book 47.1958.
Jones LH: FOOl nearment without hand tmuma.} Am Osteopath
As"" 120481,1913.
Jones LH: Missed anterior spinal lesions: a preliminary report. DO
6075, 1966.
Jones LH: Spontaneous release by positioning. 00 4:109,1964.
Jones LH: Strain and COU1l[CTStrain. Newark, Ohio, 1981. American
Academy of Osteopathy.
Jones LH: Str.tin and counterstrain lectures at Jones Institute,
I99Z-1993.
Lowen A, Lowen L: The way 10 vibranl health: a manual of bt'orner.
gelic exercises. New York, 1974,Harper & Row.
Maigue R: The concept of painlessness and opposite mmion in
spinal manipularions, Am} Phys Med 44:55,1965.
Melmck R. Stillwell DM. Fex EJ: Tngger points and acupuncture
6
22.
23.
24.
25.
26.
27.
28.
29.
CHAPTER I
30.
31.
31.
31.
H.
15.
36.
2
The Rationale for Positional
Release Therapy
Somatic Dysfunction
A New Paradigm
The Tissues
8
9
10
12
Crossroads
13
Treatment
10
Feedback
The Facilitated Segment: Neural
Tissue Connections
Summary
14
15
10
sented, and we hope (hat the reader will keep an open mind
, SOMATIC DYSFUNCTION
A NEW PARADIGM
therapeutic intervention is
CHAPTER 2
THE TISSUES
The body is composed of several major tissue types. For the
purposes of this discllssion, with respect to musculoskeletal
dysfunction, we will consider three main classes of tissue:
muscle, fascia, and bone. Even though these tissues are con
sidered separately and are often discussed in isolation from
each other in the literature, we should recognize that they
are interconnected functionally. The kinetic chain theoryli
and the rensegrity model of the body21-29 support the concept
that the effects associated with somatic lesions are trans
mined throughout the organism. Restriction or dysfunction
in one area or type of tissue can result in reactions and
symptoms in other areas of the body. Effective muscu
loskeletal therapy, including PRT, should address the source
of the dysfunction, and thus it is essential to have a thor,
ough understanding of the physiology and pathophysiology
of the somatic tissues.
The muscular system, despite its massive proportions, is
maintained in a subtle state of balance and coordination
throughout a wide range of postures and activities. The
CHAPTER 2
10
CHAPTER 2
suetch, which
sues 111 the area of the tenuer POInt soften and become less
III
local tempera
111
111
111
of the body
111
positioning
tn
CHAPTER 2
II
IntrafuSill
fibers
Extrafusal
muscle fiber
-rh",""""4''---
Encapsulating
connective
tissue
Annulospiral
Fig. 21
Muscle
bellum and the cerebral cortex and do not seem to have any
rapid change
III
III
terms of neural
III
tains ideal tone amI preparedness of the muscle and may also
fIouer spray enJmgs locateJ near the enJs of the spinJles are
fihers, repOft not only degree of ..,trctch, but also the rate of
12
CHAPTER 2
I I I I I I I I II I I I II
I I II I I
Neutral
Dysfunction
Strain
somatic dysfunction.
CHAPTER 2
I3
Cerebral centers
Central descending
pathways
to
alpha and
Skin
Triceps
(inhibited)
Phrenic
Biceps
nerve
liver. gallbladder,
and diaphragm
Su prasp inatus
Fig. 2-3
14
CHAPTER 2
area of the body may have its origin in another area and
and cerebral emotional centers) may also feed into this loop
release phenomenon. I
CHAPTER 2
15
, SUMMARY
New paradigms are emerging that are morc coru,I':otcnt with
clinical observation in the field of musculoskeletal dysfunc#
[Ion. Current m(K.lels recognizc the Intrinsic properties of
the tissues and how these arc affectcd at thc ultrastructural
Fig. 2-4
and dysfunction
trauma to one part of the body may result III pe"l>ting dys'
function in any other pan.
indicator.
associated
with
somatic
dysfunction.
N curomuscular
CHAPTER 2
16
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
1 2.
1 994, 1995.
1 3.
14.
I S.
16.
1 7.
lB.
19.
20.
21.
1985.
1995.
30.
31.
32.
33.
34.
35.
36.
41.
42.
43.
44
45.
46.
47.
48
49.
Sarno JE, Mmd VI'", hack [XUll , New York, 1982, Berkley.
SchmlJ, RF, KnlHkl KD, Schomberg ED, Dcr Eonfu" Kleon
Kahhriger Muskelaffcrenten fluf den Mukeltonus. In Bauer
HJ anJ ", her" Therapoe der S"'IIk, 1 98 1 , Veri,lg fur .nge
wilnJte WI:>.!!Cn::.chafren. Munchen.
ScuJd!. RA, Ewart NK, Trahel L The (reJrtnem of
myo(iThClal trigger points with hellUmneon and gallium.
arsenide laser: a blmJcd, crossover trial, Pam 5(suppl):768,
1990 (a\Y.,tmct).
Smith FF: Inner hridges: a guide w ('nerg)' mOl'emenl and body
srructllTt.'. Adant!,
.. 1986, Hunl<m ics New Age.
SmoklerdJ: Myofas.c.:ial (rigger '"""li nts. In Hammer W I ,
edi tor: FUllc[icnuzl sofr [!Slue exammarion and trearmem by
manum mecJlOd.s, Gau hershurg, Md, 1991. Aspen.
Snow CJ and others: RanJomlzed controlled c1mical trial
of srrcrch and l'ipray for relief of back and nec k myofasc lal
paon, Physiorher Can 44,8, 1992 (abstrdct).
T",vei l JG, S,mon; D() MyofascIlII pam and dysjomcllon, the
mgger I)Omr manual , Baltllnorc. 1983, Wdham & Wilkms.
Travcll JG, Rimier SH: The myofasc ial genc:,is of pam ,
POSlgrad Med I I A25, 1952.
Upledger JE, The facoi l tatcJ segment, Massage Ther),
Summer 1 989.
Van Bukirk RL: NociceptIVe reflexes and [he somatic dys
function, a model , ) Am Osteopath Assoc 9,792, 1 990.
Vane JR: Pam of mflamm:mon: an introduction. In Bonica
J, Lmdhlom U, 19J::o A, cdu()fs: Admnces in pain research
and dlL>ratry, vol 5, New York, 1 983. Raven Press.
50.
51.
52.
53.
54.
55.
56.
57.
58.
CIiAPTER 2
17
3
Therapeutic Decisions
Conditions of the Spine. Rihs.
Therapy?
20
Release Therapy
Contraindications to the Use
of Positional Release Therapy
20
21
23
Geriatric Patients
23
Pediatric Patients
23
Sporrs Injuries
23
Respiratory Patients
24
Amputees
24
Neurologic Patients
24
Summary
22
24
22
may be Jifferent for each tndividual, the body ha, less room
1 5 ,
..
consequence
pletely different mjuries. One may get low back pam, one
19
20
CHAPTER 3
Therapeuric Decisions
feel pain in all these areas and the fifth person may not expe
PRT is an indirect (the body part moves away from the resis
fort. Once the most severe tender poims are found, they are
Open wounds
Sutures
Healing fractures
Hematoma
informed decisions.2
Therapeutic Decisions
fortable process with the patient
10
a completely relaxed
during
CHAPTER 3
21
10
the
another modaltry.
patient's head and neck over the end of the table, it is essen
10
lifting;
underlying conditions.
22
CHAPTER 3
Therapeutic Decisions
fusion,
spondylolisthesis,
degenerative
disk
disease,
Positional Release
III
s)lmp
toms; however, thi:; is not always the case, and relief is often
optimal biomechanics.
fact,
and the WIde range of motion afforded the upper IlInbs have
III
relmion
Thera/Jeuric Decisions
CHAPTER 3
23
injuries. Most elderly patients feel that the pain in their hip
or knee is due to arthritis or is a factor of age. They do nOt
believe that much can be done for them. When confronted
with this argument, the therapist may wish to say to the
patient, "Your right and left knees are the same age, so why
did only one knee develop the arthritis?" This type of rea
soning may encourage them to reconsider their limiting
belief and thus allow them to cooperate more fully with the
treaunent program.
Usually, when elderly patients are exposed to PRT, they
quickly accept it because it is gentle and effective. Positional
release therapy may be able to release several chronic dys
functions that have been preventing the patient from
achicving a normal functional range of motion. These
patienrs are often surprised and excited with the results. They
find themselves moving more easily with less discomfort and
pcrfonning movements that they have not done in years and
assumed they had lost forever. These may include tying shoes,
looking both ways whcn driving, riding a bike, walking,
swimming, and other activities of daily living. Osteoporosis is
a consideration with this patient population. PRT may be the
treatment of choice in these cases and it is a gentle technique
which the elderly generally tolerate very well.
PE DIATRIC PATIENTS
SPORTS INJURIES
CHAPTER 3
24
Therapeutic Decisions
flaccid ann and leg tone) are not appropriate for treatment
respond as quickly.
using
an
PRT.
This
is
regional
consideration
only;
RESPIRATORY PATIENTS
10
[Q expand the rib cage more fully and with greater ease and
PRT does not treat the respIratory dISease but rather Improves
AMPUTEES
marily used
III
NEUROLOGIC PATIENTS
POSItional release therapy has been used successfully along
with craniosacral therapy, muscle energy, and myofascial
pain,
Therapeutic Decisions
References
I.
2.
l
4.
5.
6.
7.
Anderson DL: Muscle pain relief in 90 seconds: {he fold and hold
method, Minnearoli. 1995, Chronimed.
Barnes J: Myofrucial release: the search JOT excellence, 1990,
self-published.
CHAPTER 3
zs
9.
370279,1989.
10.
11.
12.
13.
4
C linical Principles
What Is the Clinical Significance
28
28
29
of Comfort
Graded?
30
28
Comfort Maintained ?
30
28
Response
31
28
Scheduling of Treatment
29
Unable to Communicate?
32
Summary
29
31
torque through the knee Over time this can lead to the
so
I AGGRAVATING FACTORS I
ICAusel
(e.g.. S-I hypomobility)
Fig. 41
""r""
" I
Global
tlerSlloS
local treatment.
27
CHArTER 4
28
Clinical Priniciples
elll
acro&> or less,
Extremely sensitive
e Very sensitive
Fig. 4-2
Moderately sensitive
No tenderness
III
In i.l
111
111
SIgn, the point is IabeleJ very serulli.'e and only the top half
of the clTcle is fdled in (e). The pattent srates that the pOint
is wuched.
In
( ). If there
Rccordmg Sheer
hown
the AppenJix.
III
Bahle"
much pam they are m, <lIld how frail their bodies are can
Clinical Principles
CHAPTER 4
29
Clmical Priniclples
CIIAPTER 4
30
Extreme 1 0
Tenderness
Severity of
Tenderness
(0- 1 0 scale)
position
111
No Tenderness 0
45
1 200
Extension
1 50
Flexion
Elbow ROM
Fig. 4-3
found that having the patient take a deep breath in anu out
mcn[ anJ the one that requires the greatest uegrce of e1in,
key is perseverance.
It IS Impormnt to remember that it IS essential, while
moving the patient's htxJy Into the treatment pOSition, [0
III
" "The patient's hoJy will tell you." This approach to [X>si-
CliniC1l1 Principles
ClIAPTER 4
31
the comfort zone, the tissues are being palpated for a release
because this will save much time and frustration later on. If
the patient has several areas of dysfunction, that is, has had
pain,
or
The goal is not to treat all the patient's tender points bur to
use the general rules and principles to help find the most
is repeated.
at ion in that area. She will often find that she is able to
the region treated but also in areas remote from the treat
CIIAPTER 4
32
Clinical Prinicip/e,
be seen twO to three times per week for local PRT sessions,
comfort zone.
manual therapy once a week and use the other Jays for exer
the
usually only occurs after the first onc or two visits.) When
USing the general rules anu principles to find the next most
too S<.)()n, the results will be more short term and the
SUMMARY
There arc nine Important points to remember when per
formmg PRT:
I . Scan the body, grade the severity of the tender
mately 90 seconds.
6. Return to neutral slowl y It is Important to memion
.
reduction
III
III
extension and
Clinical Principles
CHAPTER 4
33
(Q 30 with
References
I.
Dynamics
2.
J.
4.
5.
6.
7.
8.
9.
10.
published.
Chaitow L: The acupuncwre eTeatmenr of pain . Wellingborollh,
1976. Thorsons.
Chapman F. Owens C: fnLf'OducLion to and endocnne mrerprewuon of
Chapman's reflexes. selfpubltshcd.
O'Ambroglo K: S(T(un/counrersLTam (course syllabus), Palm Beach
Gardens, 1992, Upledger Institute.
Jones LH: SeTaln and coumt!wrain, Newark. Ohio, 1981, American
Academy of Osreopathy.
O'Connor J. Bevsky 0: AcupuncLure: a com/1l'ehensit1e rext. Seattle,
1988, Easdand Press.
Smith FF: fnner bridges-a guide to energy move-men! and bod] struc
fIIre, A tlanta , 1986, Humanics New Age.
5
Positional Release Therapy
Scanning Evaluation
Purpose of the Scanning
35
Evaluation
How to Prepare a Treatment Plan
37
Case Study I
37
Case Study 2
38
Summary
38
be implemented.
of patients.
plaint (e.g., knee pain, shoulder pain, or low back pain) but
Chapter
does one begin treating?" The SE, if used properly, will pro
rhe tender points in the SE, the practitioner will have crc
points,
categorized
detail. If you turn to the Appendix you will see a full view
into its components and explain step by step the nuts and
which can
then
be specifically
35
36
HAPTER 5
_______
Practitioner
____
_
_ 2_3_4_5 _
cles that you see beside each of the number> and abbrevia
40 in Chapter
6, Section IV, Anterior Thoracic Spine, looks like this:
40. AT I
00000
as follows:
e.Exuemely sensitive
QModernte
O-No tenderness
jump sign
fill in the whole circle (e). If the patient feels that the
point is very tender but does not have the jump sign, the
IV.
point is .ery ,ender and the top part of the circle is filled in
40. AT!
41. AT2
moderately semi,
li.e and the bottom part of the circle is filled in ("). If the
patient experiences no tenderness whatsoever, the point is
left blank (0).
eoooo
[po 85]
46. AT)00000
SO. ATtOOOOOO
QOOOO
H. ATS00000
SI ATiI 00000
45. AT600000
48. AT9
52. ATI200000
6. The exact
\ Right
/ Left
Most sensitive
YOll tum to p.
Treated
85). If
85 you will see an illustration of all the ante,
rior thoracic tender point . If you rum the page over and
look up No.
For example:
imposed on it
1 70. MK,
1 70. MK,
treatment
CHAPTER
37
As you can see the SE is very user friendly and will assist
with AT! extremely sensitive and AT7 and AT12 very sen
the keys given on p. 232 to grade the severity. Then use the
the tender points. Once the tender points that require treat
ment have been located, refer to the page number for the
being extremely sensitive after each visit and PRT does not
on the first visit, a clear picture will form showing the loc<l#
important to
5.
CaseSwyl
________
________________
to
his
[Q
10/10
For example:
IV.
Anterior Thoracic
5/10
[po 85)
43. AT4
46. AT?
eeooo
41. An eoooo
47. AT8
4z.AT3eoooo
45.AT600000
48.AT900000
51.ATlz.eooo
(PL3). Even [hough there was some soreness and palpable ten#
40. AT!
000
muscles at L3 posteriorly.
to
CHAPTER 5
38
(0
[0
was able to bear much morc weight on his right knee with less
discomfort. The knee immobilizer was not used after the first
visit, The patient returned for one more visit that week and
two visits the next week, then was discharged after a towl of
four visits. One visit was used for positional release thcrapy and
three visits for exercise prescription,.)[ which time an exercise
program to work on the mobility, flexibility, and strength of his
, SUMMARY
These case studies show how two different people can have
similar problems with range of motion, swelling, and pain in
the knee. The source of their problem was two different
regions. In the first case, it was coming from the low back;
in the second case, it was coming from the pelvic region. A
patient with knee pain may have the dominant point in the
knee. In many cases, however, the dysfunction is completely
removed from the area of pain. These cases reinforce the
knee. pelvis, and low back was srancd. This patient was off his
is
the tenderness that the patient had in his low back. By fol
Case Swdy 2
2.
____________
_
intensity. Most of the time she feels a lot of soreness and s[iff
ncss, approximately 5/10. It can get as high as 10/10 with
sudden movemcnt and movement beyond her available range.
6
Treatment Procedures
I.
UPPER QUADRANT
II.
Cranium
43
Cervical Spine
64
LOWER QUADRANT
143
144
65
150
74
159
166
Posterior Sacrum
174
75
77
Lower Limb
181
85
Knee
182
90
Ankle
193
95
Foot
204
pine
Posterior Ribs
84
100
Upper Limb
104
Shoulder
105
Elbow
126
/33
Thumb
/38
Fingers
139
ment program for the upper half of the body: the cranium,
the cervical spine, the thoracic spine and rib cage, and the
upper limb. Section II deals with the same topics for the
so
on.
SEs are provided for sections I and II, to allow the begin
Within each section the reader will find that separate areas
reflex
points
(*).
39
40
CHAPTER 6
Trearmenl Procedures
Once attempted, the user may then wish to adapt the tech.
nique to the needs of the individual if It is found that the
prescribed method is less than satisfactory. The scanning
evaluation will help the practitioner prioritizc the (feat
ment program.1 We suggest that the practitioner use the fol
lowing protocol for the most efficient use of thIS text:
l. Scan the paticm's body for tendcr points and record
them appropriately on the scanning evaluation.
2. Determme the most dominant tender pomt (DTP)
using the general rules and prinCiples.
3. Look up the appropriate treatment for the DTP. The
page reference is provided m the scanning evaluation.
4. Treat accordmg to the deSCription provided 10 the
treatment section in Chapter 6.
Treatment consists of precise positionmg of the body
part or joint in order to maximally relax the involved tis
sues. The descriptions of the poSitions of comfort are pre
sented in their gross form. The ideal position is achieved
through the use of micromovemenrs, or finetuning.8 This
typically reduces the subjective tenderness and objective
finnness of the associated tender point. Careful attention to
the subtle changes occuring in the area of the tender point
is necessary m order to obtam thc opomal release. Once
this Ideal position IS achieved. It IS held for a period of no
less than 90 seconds. During the pOSItioning. whIch may
last for 5 minutes or more, further softening, relaxation, pul.
sation, vibration, or unwinding of the tissues is often noted.
The position 109 is followed by a passive return of the
body part or jOlllt to an anatomically neutral poSition.
Reevaluation may then be carried out to confirm the em
cacy of the therapeutic intervention. This approach will
suffice for the majority of cases and will provide valuable
experience m the development of the kills necessary to
refine this art.
I UPPER
PRT
QUADRANT
Patient's name
; Extremely sensitive
\ - Right
I.
OM
0CC
PSB
LAM
SH
; Most sensitive
No tenderness
0; Treatment
00000
00000
00000
00000
00000
6.
7.
B.
9.
10.
DG
MPT
LPT
MAS
MAX
NAS
SO
FR
SAG
LSB
00000
00000
00000
00000
00000
16.
17.
lB.
19.
AT
PT
TPA
TPP
00000
00000
00000
00000
00000
00000
00000
00000
26. AC7
27. ACB
2B. AMC
00000
00000
00000
29. LCI
30. LC
30. LC
00000
00000
00000
00000
00000
00000
37. PC6
3B. PC7
39. PCB
00000
00000
00000
00000
00000
00000
46. AT7
47. ATB
4B. AT9
00000
00000
00000
49. ATlO
50. AT lI
51. AT l2
00000
00000
00000
00000
00000
00000
00000
00000
62.
63.
64.
65.
66.
00000
00000
00000
00000
00000
67. MRB
6B. MR 9
69. MRIO
00000
00000
00000
00000
00000
00000
00000
00000
76. PT7
77. PTB
7B. PT9
00000
00000
00000
79. PT lO
BO. PTlI
B1. PT l2
00000
00000
00000
00000
00000
00000
00000
00000
II.
12.
13.
14.
IS.
00000
00000
00000
23. AC4
24. AC5
25. AC6
00000
00000
00000
34. PC3
35. PC4
36. PC5
00000
00000
00000
00000
00000
00000
43. AT4
44. AT5
45. AT6
52.
53.
54.
55.
56.
VI.
/ - Left
40. AT l
41. ATZ
42. AT3
V.
31. PCI-F
32. PCI-E
33. PC2
IV.
20. ACI
21. AC2
22. AC3
111.
e Very sensitive
I.
2.
3.
4.
5.
II.
Dates
ARI
AR2
AR3
AR4
AR5
00000
00000
00000
00000
00000
57.
5B.
59.
60.
61.
AR6
AR7
ARB
AR9
ARlO
MR3
MR4
MR5
MR6
MR7
70. PTI
71. PT2
72. PT3
00000
00000
00000
73. PT4
74. PT5
75. PT6
41
Vll.
82. PRI
83. PR2
84. PR3
Vlli.
Shoulder (pages
94.
95.
96.
97.
98.
IX.
TRA
SC L
AAC
SSL
BLH
Elbow (pages
114. LEP
liS. MEP
x.
85. PR4
86. PR5
87. PR6
00000
00000
00000
88. PR7
89. PR8
90. PR9
00000
00000
00000
91. PRIO
92. PRII
93. PRI2
00000
00000
00000
105125)
00000
00000
00000
00000
00000
99.
100.
101.
102.
103.
SUB
SER
MHU
BSH
PMA
00000
00000
00000
00000
00000
104.
105.
106.
107.
108.
PMI
LD
PAC
SSM
MSC
00000
00000
00000
00000
00000
109.
110.
Ill.
112.
113.
ISS
ISM
lSI
TMA
TMI
00000
00000
00000
00000
00000
00000
00000
118. MCD
119. LCD
00000
00000
120. M O L
121. LOL
00000
00000
00000
00000
126. CMI
127. PIN
00000
00000
128. D I N
129. IP
00000
00000
126132)
00000
00000
122. CFT
123. CET
42
00000
00000
00000
116. RHS
117. RHP
133137)
00000
00000
124. PWR
125. DWR
C RANIUM
, CRANIAL DVSFUNGION
It is not within the scope of this text to delineate an exhaus#
[lve treatise on the complex functional anammy of the era,
mum. TI1.C reader houkl refer to the resources listed in the
Appendix (0 obtain training In thi important and clini#
cally relevant region. It is recommended that an anatomy
text and the drawings at the beginning of this section be
reviewed In order (0 familiarize oneself with the basic
anaromlC relationships.
For many practitioners. cranial lesions may present ehal,
lenges 111 terms of diagnosis and treatment. Mobility and
motihty (self,actuared movement) within the cranium has
now been well established, although it is not fully accepted
10 all circles. Sutherland," Upledger," and others have
useJ various mcrhoJs of diagnosis and [rcarmenr [Q nor'
malize the function of this important area of the body. Cra
nial function may have il significant bearing on the circula
tion of the cerehrospinal fluid (CSF) to the central nervous
syrem and thu:, on the functioning of the entire nervous
system.!l Dysfunctions caused by injuries, including birth
trauma and persisting lesions resulting from childhooJ
inJUries, <lre nm uncommon. MoLlem methods of birthing
may h.we a slgnlfic,uH effect on the prevalence of lateral
strain lesions of the sphenoid and compression lesions of
the temporoparietal suture.
HREATMENT
Commonly used methods of cranial manipulation involve
direct force against the movement barrier. Positiomll release
therapy uses primarily indirect movement. Tender points
are usually located in the vicinity of the cranial suture, With
certam exceptions. The amount of force is in the range o( 1
to 2 kg (2 to SIb).
4^
eRANIU M
Tender Points
_________
_
FR
LAM
SO
PSB
NAS
OCC
MAX
OM
MAS
MPT
Anterior View
---.----
PT
TPP
Posterior View
TPA
....f-I
. c++-'- LSB
-\----"l
E)"t-----.,.,-SAG
Lateral View
44
Superior View
Treannem Procedures
1 . Occipitomastoid ( OM )
--r-------<;
Parietal bone
OCCipital
bone
LAM
ace
45
Tentorium Cerebelli
Sagittal
suture
PSB
CHAPTER 6
Lambdoidal
suture
--\r--''''
1'''irl--
OM
OM
Mandible
Location of
Tender Point
Position of
Treatment
(Unilaleral
tenderness)
Position of
Treatment
(Bilateral
tenderness)
This tender point is located on the oCcipitomastoid suture just medial and superior
to the mastoid process. Pressure is applied anterosuperiorly.
Patient lies supine. The therapist sits at the head of the table and grasps the cranium
laterally with both palms. Pressure is applied medially. and counterrotation of both
temporal bones is produced around a transverse axis. The direction of the rotary
force is determined by the comfort of the patient or by the response of the tender
point (which may be difficult to palpate). (See photo above left.)
The patient lies supine. The therapist sits at the head of the table. The therapist
grasps the occipital bone and applies an anterior and caudal pressure and with the
other hand applies pressure posteriorly and caudally. The occipital hand exerts a
greater force. (See photo above right.)
46
CHAPTER 6
Treacmem Procedures
CRANIUM
2. Occipital ( OCC)
Sagittal
suture
--r------<;
Parietal bone
Occipital
bone
LA M
PSB
oee
Lambdoidal
suture
----'<'r
OM
Mandible
Tender Point
Position of
Location of
Treatment
This tender point is located medial to the lambdoid suture approximately 3 cm (1.2
in.) lateral to the posterior occipital protuberance just cephalad to the OM tender
point. Pressure is applied anteriorly.
The patient is supine. The therapist is at the head of the table and grasps both mas
toid processes with the heel and fingertips of the same hand or with the heels of
both hands. Gentle pressure is applied medially. (See photo above left.)
Alternatively. the palpating hand is placed under the occiput. the other hand is placed
on the anterior aspect of the frontal bone. and an anterior-posterior (AP) pressure
is applied. (See photo above right.)
Treaunent Procedures
CIIAPTER 6
47
Sphenobasilar Rotation
Sagictal
suture
Parietal bone
PSB
OCcipital
bone
LAM
PSB
OCC
Lambdoidal
suture
OM
L
Location of
Tender Point
Position of
Treatment
Mandible
This tender point is located just medial to the lambdoid suture approximately 3 cm
( 1 .2 in.) superior to and 3 cm (1.2 in.) lateral and slightly superior to the posterior
occipital protuberance. Pressure is applied anteriorly.
The patient is supine. The therapist sits at the head of the table and grasps the
cranium with one hand on the frontal bone and one hand on the occipital bone.
Pressure is exerted in a counterrotary direction around the AP axis. The direction
of the rotation is determined by the comfort of the patient or by the response of
the tender point (which may be difficult to palpate during the treatment).
CHAPTER 6
48
Treatment Procedures
CRANIUM
4. Lambda ( LAM)
Occipital Rotation
Sagittal
suture
Parietal bone
LAM
Occipital
bone
LAM
PSB
OCC
Lambdoidal
suture
OM
Location of
Tender Point
Position of
Treatment
This tender point is located medial to the lambdoid suture approximately 2 cm (0.8
in.) inferior to the lambda. Pressure is applied anteriorly.
The patient is supine. The therapist applies anterior pressure to the occipital bone, at
the level of the tender point, on the opposite side.
Treatmenl Procedures
CHAPTER 6
49
5 . Stylohyoid (SH)
TPA
Temporalis
FR
LSB
Lateral
pterygoid
PT
TPP
AT
Styloid
process
MAS
- - - - DG
-
Location of
Tender Point
Position of
Treatment
- MPT
Mastoid
process
SH
Masseter
Digastric
(anterior belly)
bone
This tender point is located on the styloid process just anterior and medial to the
mastoid process (pressure is medial).
The patient is supine. The therapist flexes the upper cervical spine, opens the
patient's mouth, and pushes the mandible toward the tender point side.
Alternatively, the hyoid bone is pushed from the opposite side toward the tender
point side (not shown).
CHAPTER 6
50
Treatmenr Procedures
CRANIUM
6. Digastric ( DG)
Sphenoid
--'V-""':'/1'I
Zygomatic
process
Lateral pterygoid
process
Digastric -->.,;
(posterior belly)
f----f- Medial
pterygoid
S<ylohyoid
Hyoid bone
Location of
Tender Point
Position of
Treatment
Digastric
(anterior belly)
This tender point is located in the anterior belly of the digastric muscle just medial
to the inferior ramus of the mandible and anterior to the angle of the mandible.
Pressure is applied in a cephalad direction.
Treatment Procedures
5I
CHAPTER 6
PT
TPP
_---.l0___- MAS
LC
- - MPT
MastOid;;-::X&'
proc:ess
Digastric: -
(posterior belly)
V,II----f- Medial
pterygoid
MPT
Stylohyoid
Hyoid bone
location of
Tender Point
Position of
Treatment
Digastric:
(anterior belly)
This tender point is located on the medial surface of the ascending ramus of the
mandible, just superior to the mandibular angle. Pressure is applied laterally.
The patient is supine with the therapist at the head of the table. The therapist
pushes the mandible away from the tender point side while applying a stabilizing
force on the contralateral side of the frontal bone.
Note:
CHAPTER 6
52
Treatment Procedures
CRANIUM
Sphenoid
TPA
ZygomatiC
PT
:-,.-_-AT
TPP
SH
OM --
- - - LPT
.....
--'i'-- MAS
LC
....
. - - - - DG
- - MPT
l
location of
Tender Point
Position of
Treatment
'
- - - - LPT
process
Digastric -
(posterior belly)
Stylohyoid
ii:Medial
,
pterygoid
Hyoid bone
I . Intraorally, medial to the coronoid process of the mandible in the posterior and
superior aspect of the cheek pouch on the lateral aspect of the lateral pterygoid
plate. Use a gloved finger. Pressure is applied posteriorly.
2. Extraorally, with the mouth slightly open, just anterior to the articular process of
the mandible and inferior to the zygomatic arch.
The patient lies supine. The patient's jaw is opened slightly and the head is supported
and placed in a position moderate flexion, rotation, and side bending away from the
tender point side.
Note:
Treatment Procedures
9. Masseter (MAS)
PT
AT
MAS
- - MPT
Location of
Tender Point
Position of
Treatment
53
Masseter, Temporalis
TPA
TPP
SH
OM
CHAPTER 6
Temporalis
Styloid
process
Mastoid
process
lateral
pterygoId
Masseter
Digastric
(anterior belly)
This tender point is located on the anterior border of the masseter muscle over the
anterior edge of ascending ramus of the mandible. Pressure is applied posteriorly.
The patient is supine. The therapist braces the patient's head against the therapist's
chest. The jaw is pushed toward the side of the tender point, and closure pressure is
applied on the mandible toward the tender point side while applying a counterforce
on the ipsilateral aspect of the frontal bone toward the opposite side.
CHArTER 6
54
Treatment Procedures
CRANIUM
1 0. Maxilla (MAX)
Frontal bone
FR
SO
NAS ===---
MAX
MAS
Location of
Tender Point
Position of
Treatment
......
Temporal
bone -.u-\-;;!)1i
Nasal bone
Parietal bone
.:T-H+ Sphenoid bone
Zygomatic bone
'w-r-N'Y'{Y1.,;::;'t- Maxilla
This tender point is located in the region of the infraorbital foramen. Pressure is
applied posteriorly.
The patient is supine. The therapist interlaces his or her fingers and compresses
medially with the heels of both hands on the zygomatic portion of the maxillary
bones.
Treatment Procedures
1 1 . Nasal (NAS)
CIIAPTER 6
55
Internasal Suture
Frontal bone
Parietal bone
Temporal---,bone ","u
Nasal bone -I:!--'G,..
NAS
Location of
Tender Point
Position of
Treatment
Zygomatic bone
This tender point is located on the anterolateral aspect of the nose. Pressure is
applied posteromedially.
The patient is supine. The therapist pushes medially on the portion of the nose con
tralateral to the tender point.
CHAPTER 6
56
Treatment Procedures
CRANIUM
1 2. Supraorbital ( SO)
Frontonasal J oint
Frontal bone
Parietal bone
_-i\CT SO
Temporal
bone
Nasal bone -lrQ"i
Zygomatic bone
,""""'NV\IV\;:;:;Ifflt-- Maxil a
Location of
Tender Point
Position of
Treatment
This tender point is located in the region of the supraorbital foramen. Pressure is
applied posteriorly.
The patient is supine. The therapist places his or her forearm on the patient's fore
head and pulls in a cephalad direction while pinching the nasal bones with the fingers
of the other hand and pulling in a caudad direction.
Treatment Procedures
CHAPTER 6
57
1 3 . Frontal (FR)
TPA
PT
:...:..-_- AT
- - - LPT
Parietal bone
Temporal bone
OCcipital bone
_
_
---,_
FR
Sphenoid bone
.!<t'k.':-" Nasal bone
;:';-'7F--= Maxi
Zygomatic bone
la
t1
_-ir---
MAS
IIIiIIJIooi - - - - DG
-, MPT
Location of
Tender Point
Position of
Treatment
Mandible
This tender point is located above the lateral portion of the orbit on the frontal
bone. Pressure is applied medially.
The patient is supine. The therapist pushes the top of the frontal bone caudally (see
photo above left) or compresses the frontal bone bilaterally (see photo above right).
CHAPTER 6
58
Treatment Procedures
CRANIUM
Falx Cerebri
Frontal bone
SAG
Sagittai -+
suture
--1-3
_
_
_
-If-
Parietal
bone
OCCipital bone
Location of
Tender Point
Position of
Treatment
This tender point is located on the superior aspect of the head just lateral to and
along either side of the sagittal suture. Pressure is applied caudally.
The patient is supine. The therapist pushes caudally on the parietal bone just lateral
to the sagittal suture on the opposite side of the tender point.
Treatment Procedures
TPA
PT
AT
MAS
CHAPTER 6
59
Parietal bone
Temporal bone
Occipital bone
<
'--,
<:
Frontal bone
Sphenoid bone
Nasal bone
LSB
Zygomatic bone
Maxilla
- MPT
Location of
Tender Point
Position of
Treatment
This tender point is located on the lateral aspect of the greater wing of the sphenoid
in a depression behind the lateral ridge of the orbit. Pressure is applied medially.
The patient is supine. The therapist applies a lateral pressure on the opposite greater
wing of the sphenoid toward the tender point side. A counterpressure is used on
the frontal bone and the zygoma of the involved side using the fingers and heel of
the hand.
60
CHAPTER 6
Treatmenl Procedures
CRANIUM
1 6. Anterior Temporalis ( AT )
TPA
__ PT
Parietal bone
Location of
Tender Point
Position of
Treatment
MAS
Frontal bone
Sphenoid bone
....,'"
... '
><' Nasal bone
Temporal bone
=-_- AT
_----,IF--
_
-.
-__
OCCipital bone
Zygomatic bone
:;;;o-;f'-1i:.: Maxi
la
r1
AT
This tender point is located in the anterior fibers of the temporalis muscle approxi
mately 2 em (0.8 in.) posterior and lateral to the orbit of the eye and superior to
the zygomatic arch. Pressure is applied medially.
The patient is supine. The therapist is on the side of the tender point and grasps the
frontal bone with one hand and applies a force around an AP axis toward the tender
point. The heel of the other hand is placed under the zygomatic bone. and pressure
is exerted in a cephalad direction.
Treatment Procedures
CHAPTER 6
61
TPA
Parietal bone
AT
MAS
-,
Occipital bone
Frontal bone
Sphenoid bone
-<{:':V Nasal bone
;-::.-:rL Zygomatic bone
Maxilla
...,
Temporal bone
PT
-?
Mastoid process
- MPT
l
Location of
Tender Point
Position of
Treatment
PT
Mandible
This tender point is located in the posterior fibers of the temporalis muscle approxi
mately 3 cm ( 1 .2 in.) anterior to the external auditory meatus superior to the zygo
matic arch. Pressure is applied medially.
The patient is supine. The therapist is on the side of the tender point. grasps the
parietal bone with one hand. and applies a force to rotate the skull around an AP
axis toward the tender point. The heel of the other hand is placed under the zygo
matic bone. and pressure is applied in a cephalad direction.
Note:
62
CHAPTER 6
Treatmem Procedures
CRANIUM
Parietal bone
Frontal bone
Sphenoid bone
Temporal bone
_
_
.::---
MAS
.!':: - - - DG
OCCipital bone
(i
Maxil a
location of
Tender Point
Position of
Treatment
(Unilateral
tenderness)
Position of
Treatment
(Bilateral
tenderness)
This tender point is located cephalad to the ear, on or just above the temporopari
etal suture. Pressure is applied medially.
The patient lies on the unaffected side with a small roll under the opposite zygo
matic area. The therapist sits near the head of the patient, grasps the parietal bone
with the fingers, and pulls the parietal bone cephalad and medially away from the
tender point side. Alternatively, the therapist may stand and apply the force with the
heel of the hand. Counterpressure is applied with the other hand in a medial direc
tion on the mastoid process on the same side as the tender paint.
The patient is supine with the therapist seated at the head of the table. The therapist
grasps the patient's cranium on both sides, just cephalad to the temporoparietal
suture on the parietal bones. A medial pressure is applied bilaterally (see bottom
right photo on p. 57).
Treaonem PmcedHre.
CIIAPTER 6
63
TPA
PT
AT
SH
Location of
Tender Point
Position of
Treatment
(Unilateral
tenderness)
Temporal bone
TPP
OCCipital bone
<
Frontal bone
Sphenoid bone
Nasal bone
Zygomatic bone
Maxil a
MAS
,
Parietal bone
Position of
Treatment
(Bi lateral
tenderness)
, MPT
Mandible
This tender point is located at the junction of the lambdoid the temporoparietal
sutures approximately 3 cm ( 1 .2 in.) posterior to the external auditory meatus, in a
depression on the skull. Pressure is applied medially.
The patient lies on the unaffected side with a small roll under the opposite zygo
matic area. The therapist applies a force superior to the tender point, on the parietal
bone, in a cephalad and medial direction in order to rotate the skull away from the
tender point side. Counterpressure is applied medially on the ipsilateral mastoid pro
cess with the other hand.
The patient lies supine with the therapist at the head of the table. The therapist
applies bilateral compression with the palms on both sides of the skull posterior to
the ears (see bottom right photo on p. 57).
C E RVI C A L S P I N E
be traced to dennatomal patterns associated with the nerve
, CERVICAL DYSFUNGION
, TREATMENT
sitate slight flexion of the neck, and both sides of the bifid
rotation and lateral flexion away from the tender point side.
segJ1'lental pattern,
pain, and C5 with whole head pain. Joncs9 also points out
assoc
iated with
64
ANT E RI O R C E R V I C A L S P I N E
Anterior View
AC I
Lateral View
Tender Points
TPA
TPP
SH
location of
Tender Point
Position of
Treatment
66
Coronal suture
Parietal bone ---..c
Frontal bone
Temporal bone
Sphenoid bone
...... "" Nasal bone
Lambdoidal
J
t--"d-- Lacrimal bone
suture
;;;-.::;f'-1'1::: Maxi
Zygomatic bone
Occipital bone
la
r1
_--....---
MAS
"-;'1__+----""""""_'+-- AC I
Mental
foramen
ZygomatiC Mandible
arch
This tender point is located on the posterior aspect of the ascending ramus of the
mandible approximately I cm (0.4 in.) superior to the angle of the mandible. Pres
sure is applied anteriorly.
The patient lies supine with the therapist sitting at the head of the table. The thera
pist grasps the sides of the patient's head and rotates the head markedly away from
the tender point side. Fine-tuning may include slight cervical flexion, extension, or
lateral flexion.
Treac:ment PrOCedtTes
ACl
AC4 --e
ACS --e
AC6 --e
AMC
Position of
Treatment
capitis -1-1"-1...dl lb
Sternocleido
mastoid
Middle scalene
'-AC7
--ACe
Tender Point
Longus Colli
Rectus capitis
anterior
Rectus capitis
lateralis
AC2
Location of
67
CHAPTER 6
AC2
Clavicle
First rib
Second rib
This tender point is located on the anterior surface of the tip of the transverse pro
cess of C2. This is located approximately I em (04 in.) inferior to the tip of the mas
toid process. Pressure is applied posteromedially.
The patient is supine with the therapist sitting at the head of the table. The therapist
grasps the sides of the patient's head and rotates the head markedly away from the
tender point side. This treatment is similar to that for AC I except that slightly more
flexion is used.
CHAPTER 6
68
Trearment Procedures
Rectus capitis
lateral is
;'l
AC2
LOngUs
capitis --\-'
\'!LC/!'f"fi.,
":::' C I
..-I
n-:;,
"
C2
C3
Sternocleido
mastoid
C4 ACJ
WIr!IiCO;S Longus Colli
. 1It::,::Ii>!
ACJ
AC4 -ACS
__
AC6 __
Clavicle
Posterior
scalene
O-AC7
- -AC8
Location of
Tender Point
Position of
Treatment
First rib
Second rib
This tender point is located on the anterior surface of the tip of the transverse pro
cess of C3 at the level of the hyoid. This area may usually be found directly posterior
to the angle of the mandible. Pressure is applied posteromedially.
The patient lies supine with the therapist sitting at the head of the table. The thera
pist grasps the patient's head and produces marked flexion to the level of C3, rota
tion away from the tender point side, and lateral flexion away from or toward the
tender point side.
Note:
The therapist may support the head on the therapist's forearm by passing it
under the head from the non-tender point side and resting the palm of the
hand on the patient's anterior shoulder on the tender point side.
Treatment Procedures
CHAPTER 6
69
Longus Colli
Rectus capitis
anterior
---\::r
Rectus capitis
lateralis
AC2
Longus
fl'lj,y'
capitis -;-..c:;
AC3
Sternocleido
mastoid
AC4 ___
ACS ___
Middle scalene
Anterior sCailene_
AC6 ___
Posterior
scalene
Location of
Tender Point
Position of
Treatment
First rib
Second rib
This tender point is located on the anterior surface of the tip of the transverse pro
cess of C4 at the level of the superior border of the thyroid cartilage. This area is
usually found just inferior and posterior to the angle of the mandible. Pressure is
applied posteromedially.
The patient lies supine with the therapist sitting at the head of the table. The thera
pist grasps the patient's head and produces moderate cervical flexion to the level of
C4 (cervical extension may be required for this segment), rotation, and lateral
flexion away from the tender point side.
Note:
The therapist may support the head on the therapist's forearm by passing it
under the head from the non-tender point side and resting the palm of the
hand on the patient's anterior shoulder on the tender point side.
CHAPTER 6
70
Treatment Procedures
Longus Colli
Rectus capitis
anterior
AC2
capitis -i-'a
AC3
AC4 _
AMC
fJs>_
Sternocleido
mastoid
ACS _
Middle scalene
AC6 _
Posterior
scalene
Clavicle
First rib
Second rib
O-AC7
--ACe
",
Location of
Tender Point
Position of
Treatment
This tender point is located on the anterior surface of the tip of the transverse pro
cess of CS at the level of the inferior border of the thyroid cartilage. Pressure is
applied posteromedially.
The patient lies supine with the therapist sitting at the head of the table. The thera
pist grasps the patient's head and produces cervical flexion down to the level of the
tender point and rotation and lateral flexion away from the tender point side.
Note:
The therapist may support the head on the therapist's forearm by passing it
under the head from the non-tender point side and resting the palm of the
hand on the patient's anterior shoulder on the tender point side.
Treatment Procedures
71
CIIAPTER 6
AC2
capitis -""t-\"I...c.:'Dt Y.
AC3 _
AC4
AMC
Sternocleido
mastoid
AC5
Middle scalene
Anterior ,c.,lon.,_
AC6 _
Posterior
scalene
First rib
Second rib
::'-AC7
- -ACe
l
Location of
Tender Point
Position of
Treatment
This tender point is located on the anterior surface of the tip of the transverse pro
cess of C6 at the level of the cricoid cartilage. Pressure is applied posteromedially.
The patient lies supine with the therapist sitting at the head of the table. The thera
pist grasps the patient's head and produces cervical flexion down to the level of the
tender point and rotation and lateral flexion away from the tender point side.
Note:
The therapist may support the head on the therapist's forearm by passing it
under the head from the non-tender point side and resting the palm of the
hand on the patient's anterior shoulder on the tender point side.
72
CHAPTER 6
Treatment Procedures
Sternocleidomastoid
Rectus capitis
anterior
Rectus capitis
lateralis
AC2
Longus
capitis -1-fl.":;flil"'r::;'
AC3
AC4
AMC
ACS __
AC6
Sternocleido
mastoid
__
Clavicle
First rib
Second rib
- -ACS
Location of
Tender Point
Position of
Treatment
This tender point is located on the posterior superior surface of the clavicle approx
imately 3 cm ( 1 .2 in.) lateral to the medial head of the clavicle. Pressure is applied
anteriorly and inferiorly.
The patient lies supine with the therapist sitting at the head of the table. The thera
pist supports the patient's midcervical area and markedly flexes and laterally flexes
the cervical spine toward the tender point side, rotating the cervical spine slightly
away from the tender point side.
Treatmenr Procedures
CHAPTER 6
73
Sternohyoid, Omohyoid
Rectus capitis
Basilar part of
anterior
occipital bone
Rectus capitis
lateralis
AC2
Longus
capitis -"i-'JJ
AC3
AC4 _
AMC
AC5 _
,,.....::;;:)
Sternocleido
mastoid
Middle scalene
Anterior swlene_
AC6 _
Posterior
scalene
First rib
Second rib
--Ace
'1
location of
Tender Point
Position of
Treatment
This tender point is located on the medial surface of the proximal head of the clav
icle. Pressure is applied laterally.
The patient lies supine with the therapist at the head of the table. The therapist grasps
the patient's head and flexes the cervical spine slightly, laterally flexes slightly away from
the tender point side, and rotates markedly away from the tender point side.
CHAPTER 6
74
Treatment Procedures
Rectus capitis
Basilar part of
anterior
occipital
bone
Rectus capitis
lateralis
AC2
Longus
capitis -i-'C4
AC3
AC4 __
Sternocleido
mastoid
ACS __
Middle scalene
AC6 __
Posterior
scalene
AMC
Clavicle
First rib
Second rib
O-AC7
Ace
_
_
_
.....I
Location of
Tender Point
Position of
Treatment
These tender points are found along the lateral aspect of the trachea. The trachea is
pushed slightly to the side to palpate the point. Pressure is applied posteriorly.
The patient lies supine with the therapist sitting at the head of the table. The thera
pist grasps the patient's head and markedly flexes the neck while adding slight side
bending toward and rotation away from the tender point side.
Treatment Procedures
CHAPTER 6
75
LATERAL CERVICAL
LC I----'
location of
Tender Point
Position of
Treatment
...-+
- MAS
= --cl
AC I
- - . MPT
This tender point is located on the lateral aspect of the transverse process of C I .
Pressure is applied medially.
The patient is supine with the therapist sitting at the table. The therapist grasps the
patient's head and laterally flexes the head toward or away from the tender point
side depending on the response of the tissues.
Trearmem Procedures
CHAPTER 6
76
LATERAL CERVICAL
Scalenus Medius
LCI
LC2
LC3
SH
ce'--Cl
ACI
Location of
Tender Point
Position of
Treatment
- - - LPT
MAS
--. MPT
C4
cs
C6
LC4
LCS
LC6
These tender points are located on the lateral aspect of the articular processes of
the cervical vertebrae. Pressure is applied medially.
The patient is supine with the therapist at the head of the table. The therapist grasps
the patient's head and side bends the head and neck toward or away from the
tender point side depending on the response of the tissues. Flexion, extension, or
rotation may be needed to fine-tune the position.
P 0 S T E RI O R C E R V I C A L S P I N E Tender
Points
Posterior
Rectus minor
capitis Posterior
major
PC 2
::S;
Transverse
process of C I
PC3
PC4
PC6
PC7
PCB
,,", -/
:\''"it't---f- :Superior
-rl-i]
Obius
capitis
Lonus Rotatores
BrevIs
cervicis
==:::-
Letor
77
PCI
PCI-t--_
PCI-E
..
PC6
PC7
___
pca -Location of
Tender Point
Position of
Treatment
78
This tender point is located on the base of the skull on the medial side of the inser
tion of the semispinalis capitis approximately 3 cm ( 1 .2 in.) inferior to the posterior
occipital protuberance. Pressure is applied laterally and superiorly.
The patient lies supine with the therapist sitting at the head of the table. The thera
pist grasps the patient's head by putting one hand on the occiput and pulling in a
cephalad direction and the other hand on the frontal bone pushing caudad. This will
create marked occipital flexion. Fine-tuning may include slight side bending toward
and rotation away from the tender point side.
Treatment Procedures
HAPTER 6
79
PCI
PC I -E
PC I -E -_--'
PC2 ---
PC6----
PC7
.----.
PC8 -
Location of
Tender Point
Position of
Treatment
This tender point is located on a flat portion of the occipital bone approximately
I to 1.5 em (0.4 to 0.6 in.) medial to the mastoid process. Pressure is applied in a
cephalad direction.
The patient lies supine with the head resting on the table. The therapist sits at the
head of the table. The therapist then places the hand under the patient's head with
the fingers pointing caudally. With pressure from the heel of the hand, the therapist
pushes caudally on the head in such a manner as to induce a local extension of the
occiput on C I . The therapist can also add moderate rotation and slight side bending
away from the tender point side to fine-tune.
Note:
One hand may be used to palpate the tender point and to apply caudal pres
sure on the top of the posterior aspect of the head; the other hand is posi
tioned on the frontal bone to assist the movement (not shown).
80
CHAPTER 6
Treatment Procedures
Major/Minor
1,.-;;...--r PC2
PC I -F
....
PCI-E-----.;
PC3
PC6
. . .
_
..
.
--
PC7 -
Pce------
Location of
Tender Point
Position of
'
Treatment
This tender point is located on the base of the skull on the lateral side of the inser
tion of the semispinalis capitis. Pressure is applied medially and superiorly. Another
tender point may be found on the superior surface of the spinous process of C2.
Pressure is applied inferiorly.
The patient lies supine with the head resting on the table. The therapist sits at the
head of the table. The therapist then places the hand under the patient's head with
the fingers pointing caudally. With pressure from the heel of the hand, the therapist
pushes caudally on the head in such a manner as to induce a local extension of the
occiput on C I . The therapist can also add moderate rotation and slight side bending
away from the tender point side to fine-tune.
Note:
One hand may be used to palpate the tender point and to apply caudal pres
sure on the top of the posterior aspect of the head; the other hand is posi
tioned on the frontal bone to assist the movement (not shown).
Treatment Procedures
CHAPTER 6
PCI-F
PC I-E--_-.:
J...-- PC3
PC6----
PC7
___
pca--
Location of
Tender Point
Position of
Treatment
This tender point is located on the inferior surface of the spinous process of C2
(pressure applied superiorly) or on the articular process of C3 (pressure applied
anteriorly). Slight flexion may be needed to allow the tender point to be accessible.
The patient lies supine with the therapist sitting at the head of the table. The thera
pist grasps the patient's head and extends the cervical spine to the level of C3 and
laterally flexes and rotates it away from the tender point side. This lesion may
require flexion, in which case the treatment is identical to that for AC3.
81
82
CHAPTER 6
Treatment Procedures
-..
PC6-
PC7
____
pcs--
Location of
Tender Point
Position of
Treatment
PC4
PC5
PC6
r_
------I
--: t:2
PC7 ----:;:;
-
This tender point is located on the inferior surface of the spinous process of verte
brae above (pressure applied superiorly) or on the articular process of the involved
vertebral segment (pressure applied anteriorly). Slight flexion may be needed to
allow the tender point to be accessible.
The patient lies supine with the therapist sitting at the head of the table. The thera
pist grasps the patient's head and extends it moderately and laterally flexes and
rotates it away from the tender point side. Extension is increased progressively as
one treats progressively caudal lesions.
Trearmenr Procedures
CHAPTER 6
83
Levator Costorum
PCI-F
PCI-E-_-.:
PC3 ---:-
PC6-----
---. . .
___
PC7 -
PCB
pcslocation of
Tender Point
Position of
Treatment
The therapist palpates anterior to the upper portion of the trapezius to locate the
upper border of the first rib_ The tender point is found by palpating medially toward
the base of the neck until the transverse process of C7 is encountered and then
moving onto the posterosuperior surface of the transverse process_ Pressure is
applied anteriorly on the posterior surface of the transverse process of C7_
The patient lies supine with the therapist Sitting at the head of the table. The thera
pist grasps the patient's head and induces marked lateral flexion and slight rotation
away from the tender point side along with slight cervical extension.
of fixation.
Posterior tender points may be found on the spinous pro;
cesses, in the paraspinal musculature, on the transverse pro
HREATMENT
84
Points
ATI
Internal
intercostals
Transversus
thoracis
External
intercostals
Location of
Tender Point
(All)
Location of
Tender Point
(An)
Location of
Tender Point
(All)
Position of
Treatment
ATl
This tender point is located on the superior surface of the suprasternal notch. Pres
sure is applied inferiorly.
This tender point is located on the anterior surface of the manubrium. Pressure is
applied posteriorly.
This tender point is located on the anterior surface of the sternum on or just infe
rior to the sternomanubrial joint. Pressure is applied posteriorly.
The patient sits in front of the therapist with knees flexed and hands on top of the
head. A pillow may be used between the patient and therapist for comfort. The ther
apist places his or her arms around the patient and under the patient's axillae. The
patient leans back toward the therapist, and the therapist allows the patient to slump
into marked flexion down to the level of the tender point. The patient's trunk is
folded over the tender point. Fine-tuning is accomplished with the addition of rota
tion or lateral flexion.
Note:
86
ATl
Treatment Procedures
87
CHAPTER 6
ATI
An
AT3
AT4
ATS
AT6
AT7
location of
Tender Point
Internal
intercostals
Transversus
thoracis
External
intercostals
AT4
ATS
AT6
This tender point is located on the anterior surface of the sternum at the level of
the fourth interspace. Pressure is applied posteriorly.
(AT4)
location of
Tender Point
This tender point is located on the anterior surface of the sternum at the level of
the fifth interspace. Pressure is applied posteriorly.
(ATS)
location of
Tender Point
This tender point is located on the anterior surface of the sternum at the level of
the sixth interspace. Pressure is applied posteriorly.
(AT6)
Position of
Treatment
The patient is seated in front of the therapist with the knees flexed and the arms
extended off the back of the table. A pillow may be used between the patient and the
therapist for comfort. The patient leans back toward the therapist. The therapist
places pressure on the patient's upper back to create thoracic flexion down to the
level of the tender point. The flexion is progressively increased as the level of treat
ment proceeds caudally. Local flexion may be augmented by grasping one or both of
the patient's arms and applying caudal traction and internal rotation or by having the
patient clasp his or her hands behind the therapist's knee. Fine-tuning is accomplished
with the addition of rotation or lateral flexion (see photo above left). The photo
above right illustrates an alternate, lateral recumbent position.
88
CHAPTER 6
Treacment Procedures
ATI
Location of
Tender Point
(AT1)
Location of
Tender Point
(AT8)
l
Location of
Tender Point
(AT9)
Position of
Treatment
This tender point is located on the inferior, posterior surface of the costochondral
portion of the seventh rib (pressure applied anteriorly and superiorly), approximately
I cm (0.4 in.) inferior to the xyphoid process and I cm (0.4 in.) lateral to the mid
line. Pressure is applied posteriorly.
This tender point is located approximately 3 to 4 cm (1.2 to 1.6 in.) inferior to the
xyphoid process and 1.5 cm (0.6 in.) lateral to the midline. Pressure is applied
posteriorly.
This tender point is located approximately
and 1.5 cm (0.6 in.) late
.
Assume, for the purposes of illustration, that the tender point is on the right side.
The patient sits in front of the therapist with the therapist's left foot on the table to
the left side of the patient. The patient rests his or her legs on the table with the
knees pointing to the left while the left arm rests on the therapist's left thigh. The
therapist flexes the patient's trunk down to the level of the tender point and side
bends the trunk to the right by translating it to the left. The therapist then rotates
the patient's trunk to the left by having the patient bring the right arm across the
body and grasp the left wrist.
Note:
A physical therapy ball or chair may be used to support the arm for AT 7-9.
Treacmem Procedures
CHAPTER 6
89
::-;Jr+- AT7
'-F-f- AT8
An
ATI
ATiO
ATII
location of
Tender Point
This tender point is located approximately 1.5 cm (0.6 in.) caudal to the umbilicus
and I .S cm (0.6 in.) lateral to the midline. Pressure is applied posteriorly.
(ATlO)
1
location of
Tender Point
This tender point is located approximately 4 cm (1.6 in.) caudal to the umbilicus and
2 cm (0.8 in.) lateral to the midline. Pressure is applied posteriorly.
(ATlI)
location of
Tender Point
This tender point is located on the inner table of the crest of the ilium at the midax
illary line. Pressure is applied caudally and laterally.
(ATl2)
Position of
Treatment
The patient is supine and the therapist stands on the tender point side. The head of
the table may be raised or a pillow may be placed under the patient's pelvis. The
patient's hips are markedly flexed and may be rested on the therapist's upraised
thigh. The thighs are rotated toward the tender point side, and lateral flexion may be
toward or away from the side of the tender point.
Note:
Treatments for AT I 0-12 are similar, with slight variation in fine-tuning. A phys
ical therapy ball may be used to support the legs. AT7-9 may be performed in
the supine or lateral recumbent position.
AN T E RIO R AN D
M E D I A L RIB S
Tender Points
----1t
AR2
AR3--....w...
ARS -_
AR6- . ...._-AR7---\,e
ARB ----'Ie'___
AR9 --,.::.;
ARlO
--1i;,:L..._i==k1).J
Anterior Rib Cage
90
MR3-IO
:::---..
AR2 __
AR3_
AR4-.-.
ARS
AR6
AR7
ARB
AR9
ARlO
ARI
Location of
Tender Point
Position of
Treatment
MR3-IO
Internal
intercostals
Transversus
thoracis
External
intercostals
This tender point is located on the first costal cartilage immediately inferior to the
proximal head of the clavicle. Pressure is applied posteriorly.
The patient may be supine or sitting. The therapist grasps the head and places the
patient's neck in slight flexion, marked lateral flexion toward the tender point, and
slight rotation (usually toward the tender point) to fine-tune the position.
91
92
Treatment Procedures
CHAPTER 6
Scalenus Posterior
AR I :::::----..
AR2 __
AR3_
AR4-.
AR5
AR6
AR7
ARB
AR9
ARlO
Location of
Tender Point
Position of
Treatment
MR3-IO
Internal
intercostals
Transversus
thoracis
External
intercostals
This tender point may be found in two locations. One is on the superior surface of
the second rib inferior to the clavicle on the midclavicular line (pressure is applied
inferiorly and posteriorly). Another tender point may be found on the lateral aspect
of the second rib high in the medial axilla (pressure is applied medially).
The patient may be supine or sitting. The therapist grasps the head and places the
patient's neck in slight flexion, marked lateral flexion toward the tender pOint, and
slight rotation (usually toward the tender point) to fine-tune the position.
Treamlenr Procedllres
CHAPTER 6
93
ARI _____
AR2 __
AR3_
AR4_ MR3IO
ARS-
AR6
:
AR7
AR8
AR9
ARlO
Location of
Tender Point
Position of
Treatment
;;[2r
-AR3
to::::;S:;Q,
:; c AR4
""""f3 l -ARS
Internal intercosta Is
T
thoracis
External
intercostals""-..":>---7
ransversus>
AR6
tJL
"""
-AR7
'
AR8
ctf'-AR9
\."'l
\'<!Ii/'---ARI 0
j;",q:j=",\L-
These tender points are located on superior aspects of the ribs from the anterior
axillary line to the midaxillary line at the corresponding levels for ribs 3 through 10.
Pressure is applied inferiorly and posteromedially or medially.
Assume, for the purposes of illustration, that the tender point is on the right side.
The patient sits in front of the therapist with the therapist's left foot on the table to
the left side of the patient. The patient rests his or her legs on the table with the
knees pOinting to the left while the left arm rests on the therapist's left thigh. The
therapist flexes and side bends the patient's trunk to the right down to the level of
the tender point by translating it to the left. The therapist then rotates the patient's
trunk to the right.
Note:
94
CHAPTER 6
Treatment Procedures
ARI
AR2 __
AR3_
AR4ARS
AR6
AR7
ARB
AR9
ARlO
location of
Tender Point
Position of
Treatment
MR1-1
MR3-IO
These tender points are located on or between the costal cartilages near the ster
nocostal joints just lateral to the sternum at the corresponding level for each rib.
Pressure is applied posteriorly.
Assume, for the purpose of illustration, that the tender point is on the right side. The
patient sits in front of the therapist with the therapist's left foot on the table to the
left side of the patient. The patient rests his or her legs on the table with the knees
pOinting to the left while the left arm rests on the therapist's left thigh. The therapist
flexes and side bends the patient's trunk to the right, down to the level of the tender
point, by translating it to the left. The therapist then rotates the patient's trunk to
the left by having the patient bring his or her right arm across the body and grasp
the left wrist.
Note:
Points
PT I-2
9S
PRI
PR2
PRJ
PR4
PRS
PR6
PR7
PR8
PR9
PRIO
PRI
PRI I
Location of
Tender Point
Position of
Treatment
.---- PTI
_PTl
.-PTJ
'-PH
-PTS
-PT6
..--PT7
PT8
PT9
PTIO
. PTI I
PTI
!::
Scapula
Multifidi
External
intercostals
Levator costae
Brevis Lev.tores
Longus costarum
These tender points are located on the side of the spinous process (pressure is
medial), in the paraspinal area (pressure is anterior), or on the posterior aspect of
the transverse processes (pressure is anterior) at the corresponding levels for each
segment_
The patient lies prone with the arms alongside the trunk or abducted to 90 off the
sides of the table. The therapist stands at the head of the table and supports the
patient's head on the therapist's hand and forearm. The therapist extends the
patient's head to the level of involvement and rotates and laterally flexes the head
away from the tender point side.
Note:
96
PTI-2
PT I , 2 may be treated in the supine position by extending the head off the end
of the table and rotating and laterally flexing away from the tender point side.
Treaunenr Procedures
97
CHAPTER 6
PRI
PR2
PRJ
PR4
PRS
PR6
PR7
PRe
PR9
PRI O
PRI2
PRI I
"I
Location of
Tender Point
Position of
Treatment
PTI
_PT2
.-
._PTl
_PT"
-PTS
. . -PT6
--
___ PT7
. . ......
PT8
.. m
PTI O
. PTI I
Scapula
PTJ
PT4
PTS
Interspinales
Multifidi
External
intercostals
Levator costae
BreviS Levatores
Longus costarum
These tender points are located on the side of the spinous process (pressure is
medial), in the paraspinal area (pressure is anterior), or on the posterior aspect
of the transverse processes (pressure is anterior) at the corresponding levels for
each segment.
The patient lies prone with the arms on the table along the side of the head to
create more spinal extension. The therapist stands at the head of the table and sup
ports the patient's head with the therapist's hand and forearm. The therapist extends
the head to the level of involvement, markedly rotates, and moderately laterally
flexes the head away from the tender point side.
98
CHAPTER 6
Treatmem Procedures
PRI
PR2
PR3
PR4
PRS
PR8
Location of
Tender Point
Position of
Treatment
Clavicle
..-
PTI
_PT2
..-PT3
"-PT4
-PT5
-PT6
---. PT7
........
...
____.... PTa
PT9
PTIO
. PTII
PTll
Scapula
External
intercostals
Levator costae
Brevis Levatores
Longus costarum
These tender points are located on the side of the spinous process (pressure is
medial), in the paraspinal area (pressure is anterior), or on the posterior aspect of
the transverse processes (pressure is anterior) at the corresponding levels for
each segment.
The patient lies prone with a cushion under the chest and with the arm on the
tender point side resting alongside the head. The opposite arm is abducted to 90
resting off the side of the table or is placed alongside the trunk. The therapist stands
near the head of the table between the patient's head and shoulder on the side
opposite the tender point. The therapist grasps the axilla on the affected side and
pulls the shoulder posteriorly and in a cephalad direction, producing traction, exten
sion, rotation, and lateral flexion away from the tender point side.
Note:
The more lateral the tender point, the more flexion and rotation will be used.
Treafmem Procedures
79,81.
PRI I
Location of
Tender Point
99
PRI
PR2
PR3
PR4
PRS
PR6
PR7
PRB
PR9
PRIO
HAI'TER 6
Position of
Treatment
....-PTI
..-PT2
PT3
PT4
-PTS
-PT6
.. --
.. ..-
Clavicle
Scapula
____
PT7
......... PT8
PT9
..
. PTI
Incerspinales
_ Multifidi
Excernal
incercostals
Brevis L Levacores
costarum
ilW..."....,...,,,,,- LongusJ
PTI 0 --\iW:7Z:;1
PT I I -jj
'fi';;z;..o'b
PTI 2
-f,
These tender points are located on the side of the spinous process (pressure is
medial), in the paraspinal area (pressure is anterior), or on the posterior aspect of
the transverse processes (pressure is anterior) at the corresponding levels for
each segment.
The patient lies prone with the head end of the table raised or with cushions under
the patient's chest. The therapist stands at the level of the patient's pelvis opposite
the tender point side. The therapist reaches across the patient and grasps the ante
rior ilium on the involved side and pulls posteriorly and toward the therapist, cre
ating a rotation of the pelvis of 30 to 45. For lateral tender points additional lateral
flexion may be needed. This is accomplished by moving the patient's legs along the
table away from the tender point side (see photo above left).
Alternatively, the hip on the tender point side may be abducted and flexed (see
photo above right.)
P 0 S T E RIO R RIB S
Tender Points
PRI
PR2I O
100
Posterior Ribs
82. Posterior First Rib (PR1)
PRI
PR2
PR3
PR4
PRS
PR6
PR7
PR8
PR9
PRI O
PRI 2
PRI I
location of
Tender Point
Position of
Treatment
PTI
_PT2
..-PTJ
"-PT4
-PTS
-PT6
..-
.........
____.
____.
PT7
PT8
PT9
PTI
O
.PTI
Scapula
Multifidi
External
intercostals
levator costae
Brevis Levatores
Longus costarum
This tender point is located on the superior aspect of the first rib deep to the ante
rior margin of the upper portion of the trapezius. Pressure is applied inferiorly.
The patient is sitting with the therapist standing behind the patient. The therapist
places his or her foot on the table at the side of the patient opposite the tender
point side. The patient's axilla rests on the therapist's thigh, and the therapist trans
lates the patient's trunk away from the tender point side. The therapist supports the
patient's head against the therapist'S chest and places the neck in slight extension
and fine-tunes the position with lateral flexion (usually away) and rotation (usually
toward) the tender point side.
1 01
1 02
CHAPTER 6
Treatment ProcedlTes
Posterior Ribs
PRI
I
PR __ ..--PTI
PRJ ___ -__ PT2
-- _ PTJ
PR4-... - -_ PT4
I'K"i
r-_
_ --_ PTS
PR'7-jI----__
_..;. -__
PR,'-ir--_-...:. -- ---. PT6
PT7
__
__
PTa
__
PRln-lIl- -- PT9
.... -PTI O
PR 12 -1-1;--. -PTI I
PRI I
Clavicle
- -
!:::::
Location of
Tender Point
Position of
Treatment
PR2IO
i I
!r Multifidi
External
intercostals
'D'Y.-,\-
Levator costae
Brevis L Levatores
-rti\- LongusJ COStarum
These tender points are located on the posterior angles of the ribs. To access ribs 2
through 10 it may be necessary to protract the ipsilateral scapula by adducting the
involved arm across the chest. Pressure is applied anteriorly.
Assume, for the purposes of illustration, that the tender point is on the right side.
The patient sits in front of the therapist with the therapist's right foot on the table
to the right side of the patient. The patient rests the legs on the table with the knees
pointing to the right while the right arm rests on the therapist's right thigh. The ther
apist side bends the patient's trunk to the left by translating it to the right. The ther
apist then rotates the patient's trunk to the left.
Treatmem Procedlres
CHAPTER 6
103
PRI
PR2
PR3
PR4
PR5
PR6
PR7
PRB
PR9
PRIO
PRI
PRII
Location of
Tender Point
Position of
Treatment
Clavicle
PTI
...- _PT2
e-
PT3
e-PT4
-PTS
-PT6
.........
PT7
......
____... PT8
PT9
PTIO
. PTI
Multifidi
External
intercostals
Scapula
Levator costae
Brevis Levatores
Longus costarum
I I
Assume, for the purposes of illustration, that the tender point is on the right side.
The patient sits in front of the therapist with the therapist's left foot on the table to
the left side of the patient. The patient rests the legs on the table with the knees
pointing to the left while the left arm rests on the therapist's left thigh. The therapist
flexes and side bends the patient's trunk to the right, down to the level of the tender
point, by translating it to the left.
UPP E R LIMB
elmical presentations involving the upper limh Include
honcs.'i
III
111
'hEATMENT
use
trauma such
as
as
IS
104
SH0U L0ER
Tender Points
YIii/-f-- MHU
- SUB
,eI-+--I-
MSC
SSM PAC
1:
+lSs SSL
ISS
"'>'-f-- ISM
TMI
'-+-ISI
TMA
J?:""
LD
105
Shoulder
94. Trapezius (TRA)
SCl
TRA
MC
TRA
BlH
BSH
PMI
Subclavius
Deltoid
Pectoralis
minor (cut)
PMA --
SER
Biceps
brachii
+4J-h/...jf.4- \
long
head
Short
head
Serratus
anterior
Location of
These tender points are located along the middle portion of the upper fibers of the
Tender Point
trapezius. Pressure is applied by pinching the muscle between the thumb and fingers.
Position of
The patient is supine with the therapist standing on the side of the tender point. The
Treatment
patient's head is laterally flexed toward the tender point side. The therapist grasps
the patient's forearm and abducts the shoulder to approximately 90 and adds slight
flexion or extension to fine-tune.
106
Treatment Procedures
CHAPTER 6
107
TRA
AAe
BLH
BSH
PMI
SCL
Deltoid
---
SER
Pectoralis
minor (cut)
PMA
Subclavius
Subscapularis
Biceps
brachii
-\,1HHJICt
ong
head
Short
head
Serratus
anterior
"I
Location of
Tender Point
This tender point is located on the undersurface of the middle portion of the clav
icle. Pressure is applied superiorly and somewhat posteriorly.
Position of
I . The patient is supine and the therapist stands on the opposite side of the tender
Treatment
point. The therapist adducts the arm obliquely across the body approximately 30
and adds slight traction caudally. (See photo above left.)
2. The patient is lateral recumbent with the tender point on the superior side. The
therapist stands behind the patient and places the affected arm in slight extension
behind the patient's back. Pressure is applied to the affected shoulder to cause it
to be adducted in the transverse plane. R etraction or protraction and flexion or
extension are added for fine-tuning. (See photo above right.)
108
Trearmenr Procedures
CHAPTER 6
Shoulder
Anterior Deltoid,
TRA
AAC
AAC
BLH
BSH
PMI
Deltoid
PMA
--
SER
Location of
Tender Point
Position of
Treatment
Pectoralis
(cut)
minor
Biceps
brachii
-+-\f-IHJR-
ong
head
Short
head
This tender point is located on the anterior aspect of the acromioclavicular joint
near the distal end of the clavicle. Pressure is applied posteriorly.
I . The patient is supine. The therapist stands on the opposite side of the tender
point and grasps the patient's affected arm above the wrist. The therapist then
slightly flexes and adducts the arm obliquely across the body at an angle of
approximately 30 and adds a moderate amount of caudal traction in the direc
tion of the opposite ilium.
2. The patient is supine and the therapist stands on the side of the tender point. The
therapist grasps the affected forearm and flexes the arm to approximately 90
and fine-tunes with slight adduction and internal rotation.
Treatment Procedures
SSL
CHAPTER 6
109
Supraspinatus Tendon
----
h;:"-"<lI_ SSl
"I
Location of
Tender Point
This tender point is located deep to the belly of the lateral deltoid muscle just infe
rior to the acromion process. The therapist must flex or abduct the arm to approxi
mately 90 in order to slacken the deltoid sufficiently to allow for palpation of the
tender point. Pressure is applied inferiorly.
Position of
The patient is supine. The therapist produces a combination of flexion and abduction
Treatment
of the arm to approximately 120 and adds slight external rotation to fine-tune.
liD
Treatment Procedu.res
CHAPTER 6
Shoulder
TRA
MC
Subclavius
Subscapularis
BLH
BSH
PMI
Deltoid
PMA
---
SER
Pectoralis
minor (cut) -\-%I-.fF;'-\; \
ong
Biceps head
brachii Short
head
Serratus
anterior
Location of
Tender Point
This tender point is located on the tendon of the long head of the biceps in the
bicipital groove. Pressure is applied posteriorly.
Position of
The patient lies supine with the therapist standing on the side of the tender point.
Treatment
The therapist flexes and abducts the patient's shoulder and flexes the elbow, and the
dorsum of the patient's hand is placed on the patient's forehead. The therapist grasps
the patient's elbow and fine-tunes the pOSition by varying the amount of abduction
and internal or external rotation.
Treatmem Procedures
CHAPTER 6
III
Subscapularis
Deltoid
SUB
Pectoralis
minor (cut)
Biceps
br;achii
SUB
ong
head
Short
h..d
Serraws
anterior
Location of
Tender Point
This tender point is located on the anterior surface of the lateral border of the
scapula. Pressure is applied medially and then posteriorly.
Position of
The patient is supine with the lateral aspect of the trunk on the involved side even
Treatment
with the edge of the table. The therapist stands or sits on the tender point side and
grasps the forearm of the patient and places the shoulder in approximately 30 of
extension. adduction. and internal rotation.The shoulder may be elevated to fine
tune the position.
Treatment Procedures
CHAPTER 6
liZ
Shoulder
AAC-_.1A
BLH
Subscapularis
Deltoid
BSH
PMI
Pectoralis
incr (cut) ---+4fJ-H.P"t
PMA---
SER
Location of
Tender Point
SER
These tender points are located on the costal attachments of the serratus anterior
on the anterolateral aspects of ribs 3 through 7. Pressure is applied medially.
Position of
The patient is seated or supine. The therapist contacts the tender point with his or
Treatment
her ipsilateral hand and then grasps the involved arm anteriorly with the other hand.
The arm is drawn across the chest in horizontal adduction and flexion.
Note: These tender points are located on the lateral aspect of the ribs, whereas the
anterior rib tender points are located on the superior aspect of the ribs.
Treatment Procedures
CHAPTER 6
113
Glenohumeral Ligaments
Subclavius
Subscapularis
Deltoid
SUB
Pectoralis
minor (cut) -'c--tf;fHlI"t
ong
Biceps head
brachii Short
head
MHU
Serratus
anterior
"I
location of
Tender Point
This tender point is located high in the axilla on the medial aspect of the head of the
humerus. Pressure is applied laterally.
Position of
The patient is supine with the therapist standing on the side of the tender point. The
Treatment
therapist applies a cephalad compressive force on the elbow through the long axis of
the humerus. This position results in increased adduction of the glenohumeral joint
by reducing the scapulohumeral angle.
Treacmem Procedures
CHAPTER 6
1 14
Shoulder
TRA
MC
Subclavius
Subscapularis
BLH
aSH
Deltoid
PMI
PMA--SER
aSH
Pectoralis
minor (cut) -+'W-IHj'
Biceps
brachii
ong
head
Short
head
Serratus
anterior
Location of
Tender Point
This tender point is located on the inferior lateral aspect of the coracoid process.
Pressure is applied superiorly and medially.
Position of
The patient is supine. The therapist stands or sits on the side of the tender point,
Treatment
flexes the patient's shoulder to approximately 90 with the elbow flexed, and adds
moderate horizontal adduction.
Treatment Procedures
CHAPTER 6
115
TRA
AAC
Subclavius
Subscapularis
BLH
?
Deltoid
BSH
PMI
Pectoralis
minor (cut) -\-wtf-ll"i"
PMA---
SER
;;:;:::;;::J
ong
Biceps head
brachii Short
head
PMA
Serratus
amerior
Location of
Tender Point
This tender point is located along the lateral border of the pectoralis major muscle,
just anterior to the anterior axillary line. Pressure is applied medially.
Position of
The patient may be seated or supine. The therapist stands or sits at the side of the
Treatment
patient on the side of the tender point. The therapist flexes and adducts the patient's
involved arm across the chest and pulls the arm into hyperadduction. The therapist
fine-tunes with variable flexion.
116
CHAPTER 6
Treatment Procedures
Shoulder
SCL
TRA
AAe
BLH
BSH
PMI
PMA
Subclavius
Subscapularis
Deltoid
Pectoralis
PMI
---
SER
Serratus
anterior
Location of
Tender Point
This tender point is located on the medial inferior aspect of the coracoid process
(pressure applied superiorly and laterally) or on the anterior aspect of ribs 2. 3. and
4 just lateral to the midclavicular line (pressure applied posteriorly and medially).
Position of
The patient is sitting in front of the therapist.The therapist grasps the forearm
Treatment
and pulls it behind the patient in a hammerlock position in order to extend and
internally rotate the shoulder.The therapist then protracts the shoulder by pushing
the elbow or shoulder forward. abducting slightly and pushing anteriorly on the
involved shoulder.
Treatment Procedures
CHAPTER 6
117
"--{
"I
Location of
Tender Point
IlISSSSMI
TMI
TMA
LD
This tender point is located on the anterior medial aspect of the humerus just
medial to the bicipital groove (pressure applied posterolateraliy). Another point may
be found 2 to 3 em (0.8 to 1.2 in.) lateral to inferior angle of the scapula. Pressure is
applied anteriorly.
Position of
The patient is supine with the lateral aspect of the trunk on the involved side, even
Treatment
with the edge of the table. The therapist stands or sits on the tender point side,
grasps the forearm of the patient, and places the shoulder in approximately 3D of
extension, adduction, and internal rotation. Long-axis traction is then applied to
the arm.
1 18
CHAPTER 6
Treatmenr Procedures
Shoulder
----ISS
e-----t- ISM
lSI
TMI
_---;=
=
AC Ligament
r--- Levator
scapulae
Supraspinatus
rfI.PAC Infraspinatus
e-ilf---LD
Teres minor
11---t-T
- eres major
Location of
Tender Point
This tender point is located on the posterior aspect of the acromioclavicular joint
near the distal end of the clavicle. Pressure is applied anteriorly.
Position of
The patient is prone and the therapist stands on the side opposite the tender point.
Treatment
The therapist grasps the patient's involved arm and pulls it obliquely across the body
approximately 30 and applies caudal traction toward the opposite hip.
Treatment Procedures
-{
MOC
---1- 55
1 ISM
----+
_---.1..,. 51
e--_TMI
CHAPTER 6
1 19
Supraspinatus Muscle
c---
Levator scapulae
Supraspinatus
Infraspinatus
,.f.17
Teres minor
Location of
Tender Point
This tender point is located in the belly of the supraspinatus muscle in the
supraspinous fossa or at the musculotendinous junction just medial to the posterior
aspect of the acromioclavicular joint. Pressure is applied anteriorly and inferiorly.
Position of
Treatment
The patient lies supine. The therapist is on the side of the tender point. The therapist
grasps the forearm near the elbow and places the shoulder into 45 of flexion,
abduction, and external rotation.
120
CHAPTER 6
Treatment Procedures
Shoulder
---{
SSM
PAC
---.--- ISS
e----T ISM
_
= ISI
-;=
TMI
_--r----'TMA
"'f--.....- LD
C5:?;4
MSC
Supraspinatus
Infraspinatus
Teres minor
1"":>1-+-Teres major
Location of
These tender points are located on the superior vertebral angle of the scapula and
Tender Point
along the medial border of the scapula. Pressure is applied caudally, laterally, or both.
Position of
I . The patient is prone and the therapist stands on the side of the tender point. The
Treatment
affected arm is grasped above the wrist, extended 20 to 30, internally rotated,
and tractioned caudally.
2. The patient is prone and the therapist stands on the side of the tender point. The
patient's forearm is flexed at the elbow and the hand is placed under the affected
shoulder. The therapist pushes the lateral aspect of the inferior angle of the
scapula medially and cephalad.
3. The patient is supine. The therapist flexes the shoulder to approximately I 10
to 120 with the elbow flexed and fine-tunes the position with internal or
external rotation.
Treatment Procedures
:;;- PAC
-..
-.- 155
---- ISM
151
_-;:==:,
TMI
__-+ --'
e-#-----,,- LD
CHAPTER 6
121
,---- Levator
scapulae
Supraspinatus
rfi Infraspinatus
Location of
Tender Point
Position of
Treatment
Teres minor
;.4-+-- Teres major
This tender point is located along the inferior border of the spine of the scapula.
Pressure is applied anteriorly.
The patient is supine and the therapist is on the side of the tender point. The thera
pist grasps the forearm and flexes the shoulder to approximately 90 to 100 with
moderate horizontal abduction and slight external rotation.
CHAPTER 6
122
Treannent Procedures
Shoulder
55M PAC
1\---- Levator scapulae
Supraspinatus
Infraspinatus
-----0-155
---- I S M
_--;==3151
TMI
'--r-'T
-- MA
Mf---L- D
Location of
Tender Point
Position of
Treatment
ISM
-++-\L--..
Teres minor
04'--+-T
- eres major
This tender point is located in the upper portion of the infraspinous fossa. Pressure
is applied anteriorly.
The patient is supine and the therapist stands on the side of the tender pOint. The
therapist grasps the forearm and flexes the shoulder to approximately I 100 to 1200
with moderate horizontal abduction and slight external rotation.
Treatment Procedures
H-{
Location of
Tender Point
ISS
ISM
Levator scapulae
Supraspinatus
Infraspinatus
1TMS
51
TMA
LD
123
CiIAI'TER 6
Teres minor
IS
Teres major
This tender point is located in the central or lower portion of the infraspinous fossa.
Pressure is applied anteriorly.
Position of
The patient is supine and the therapist stands on the side of the tender point. The
Treatment
therapist grasps the forearm, flexes the shoulder to approximately 1300 to 1400, and
fine-tunes with slight abduction/adduction and internal/external rotation.
Treatment Procedures
CHAPTER 6
124
Shoulder
--- 155
--- 15M
-- 151
--TMI
--,
Supraspinatus
Infraspinatus
--
Teres minor
TMA -t-t--<.\
latissimus
dorsi
location of
Tender Point
Position of
Treatment
This tender point is located along the lateral aspect of the inferior angle of the
scapula. Pressure is applied anteromedially.
The patient sits in front of the therapist. The therapist grasps the patient's forearm,
bends the arm at the elbow, and produces marked internal rotation, adduction, and
slight extension (hammerlock position). Internal rotation may be augmented by
pulling the forearm posteriorly.
Treatment Procedures
CHAPTER 6
125
........-
.e---ISS
e-----.-ISM
_---..) lSI
Infraspinatus
ee---TMI
TMA
H-- LD
e--...r--
Teres minor
TMI
dorsi
Location of
Tender Point
This tender point is located on the upper third of the lateral border of the scapula
or along the posterior, inferior border of the axilla. Pressure is applied anteriorly,
medially, or both.
Position of
Treatment
The patient sits in front of the therapist. The therapist grasps the involved forearm,
which is bent at the elbow. The shoulder is extended to approximately 30,
adducted, and markedly externally rotated.
E L BO W
Tender Points
LEP -'"
MEP
126
Elbow
1 14. Lateral Epicondyle (LEP)
"I
This tender point is located on the supracondylar ridge superior to the lateral epi
Location of
Tender Point
RHS
RHP
LEP __
-.II
__
Position of
Treatment
lE P ---,
,.1
Treatment is directed to the first thoracic segment or the first rib. (AT I . PT I .AR I .
PR I). Check for tender points in these areas and treat according to the general
rules. Monitor the LEP tender point during and after the treatment.
127
118
CHAPTER 6
Treatment Procedures
Elbow
Location of
Tender Point
This tender point is located on the supracondylar ridge superior to the medial epi
condyle. Pressure is applied laterally.
LEP ___..
RHS
RHP
__
_
MEP
Position of
Treatment is directed to the fourth thoracic segment or the fourth rib. (AT4. PT4.
Treatment
AR4. PR4. MR4). Check for tender points in these areas and treat according to the
general rules. Monitor the MEP tender point during and after the treatment.
Treatment Procedures
CHAPTER 6
129
Supinator
Brachialis
LEP
RHP
___I.
RHS
__
RHS
Supinar.or """",!}Y
Pronator
teres
j
Pronator ____
quadratus 1.
(..u
Location of
Tender Point
This tender point is located on the anterior surface of the proximal head of the
radius. Pressure is applied posteriorly.
Position of
The patient may be seated or supine. The therapist grasps the patient's forearm and
Treatment
elbow, markedly supinates the forearm, and mildly extends the elbow. Abduction
(valgus) is used to fine-tune the position.
130
CHAPTER 6
Treatment Procedures
Elbow
Pronator Teres
',
,
Brachialis
RHP
Supinator -""g[
Pronator
teres
Pronator ---f':a
quadratus
location of
Tender Point
This tender point is located on the anterior surface of the proximal head of the
radius. Pressure is applied posteriorly.
Position of
The patient is sitting or supine. The therapist grasps the forearm and elbow and pro
Treatment
duces marked pronation and flexion at the elbow with the dorsum of the patient's
hand coming to rest on the patient's lateral trunk.
Treatment Procedures
CHAPTER 6
Brachialis
II
,,
,,
Brachialis
,,
,
RHS
RHP
__
_
13 1
LCD
MCD
$upinator"""""Mi--M
Pronator
teres
de
Pronator
,
quadratus -IT.--,
b
Location of
Tender Point
These tender points are located on the medial and lateral aspects of the coronoid
process of the ulna. Pressure is applied posteriorly.
Position of
The patient is sitting or supine. The therapist markedly flexes the elbow, pronates the
Treatment
forearm to turn the palm forward, and externally rotates the humerus.
CHAPTER 6
132
Treatmem Procedures
Elbow
Triceps
MC'L-t.f.r-- LOL
"IIl-l--- Anconeus
Tender Point
Position of
The patient is seated or supine. The therapist hyperextends and adducts (varus) or
Treatment
Location of
These tender points are located on the lateral and medial aspect of the olecranon
process. Pressure is applied medially or laterally.
W R 1 S T AND H AN 0
Tender Points
133
eFT
RHS
RHP
__
_
Common
flexor tendon
Palmaris longus
Opponens
pollicis
Abductor pollicis
(cut)
(cut)
,k(/fJ.:l!interossei
Palmar
location of
Tender Point
Position of
Treatment
This tender point is located on the anterior medial aspect of the forearm, just distal
to the medial epicondyle. Pressure is applied posterolaterally.
The patient is supine or seated. The therapist markedly palmar flexes the wrist with
the greatest force being exerted on the hypothenar side. Pronation/supination and
abduction/adduction are used to fine-tune the position.
134
Treatment Procedures
HAPTER 6
135
"_ ;
carpi
I
radialis
_ longus
Extensor
carpi ulnaris
Extensor carpi
radialis brevis
Extensor
digitorum--lr:-.11!t\"-Ir- Extensor pollicis longus
Extensor_-,...".,
indicis
DIN
Extensor pollicis
brevis
Interossei --O!f:ti:t\Jn
IP
Location of
Tender Point
Position of
Treatment
This tender point is located on the posterior lateral aspect of the forearm, just distal
to the radial head. Pressure is applied anteromedialiy.
The patient is supine or seated. The therapist markedly extends the wrist, with the
greatest force being exerted on the thenar side. Pronation/supination and abduc
tion/adduction are used to fine-tune the position.
136
CHAPTER 6
Trearmem Procedures
RHS
RHP
__
_
Location of
Tender Point
Wrist Flexors
These tender points are located along the palmar surface of the carpals. Pressure is
applied posteriorly.
Position of
The therapist faces the dorsum of the patient's wrist. The therapist palmar flexes the
Treatment
wrist over the tender point. Fine-tuning is accomplished with siding, pronation or
supination, and radial/ulnar deviation.
Treatment Procedures
CHAPTER 6
137
Wrist Extensors
DIN
IP
Location of
Tender Point
These tender points are located along the dorsal aspect of the wrist. Pressure is
applied anteriorly.
Position of
The therapist doriflexes the wrist with slight side bending toward the tender point.
Treatment
138
CHAPTIR 6
Treatment PTocedltre
Thumb
Location of
Tender Point
Position of
Treatment
This tender point is located in the thenar eminence on the palmar surface of the
first metacarpal. Pressure is applied posterolaterally.
The therapist flexes (see photo above left) or opposes (see photo above right) the
thumb over the tender point and fine-tunes the position with abduction/adduction
and internal/external rotation.
Treatmenr Procedures
CHAPTER 6
139
Fingers
Metacarpophalangeal Joints
MEP
eFT
_
RHS __
RHP
PIN
location of
Tender Point
These tender points are located within the palm of the hand, on the medial and lat
eral sides of the shafts of the metacarpals. Pressure is applied posteromedially or
posterolaterally.
Position of
The therapist markedly flexes the fingers over the tender point with the addition of
Treatment
lateral flexion toward the tender point and rotation to fine-tune the position.
140
CHAPTER 6
Treatment Procedures
Fingers
Metacarpophalangeal Joints
DIN[
...._IP
...
Location of
Tender Point
These tender points are located on the dorsum of the hand. on the medial and lat
eral sides of the shafts of the metacarpals. Pressure is applied anteromedially or
anterolaterally.
Position of
The therapist markedly extends the finger over the tender point with the addition of
Treatment
lateral flexion toward the tender point and rotation to fine-tune the position.
Treatment Procedures
CHAPTER 6
141
Capsular Ligaments
Leo
.
-'r.
eFT
'i
RHS __
_
tendon
Flexor carpi
radialis
RHP
,..
flexor
MEP
OJ',
Common
Meo
Palmaris
longus
Opponens
"' ..
pollicis
Abductor
pollicis
carpi
ulnaris
Palmar
(cut)
PWR
"'
.
PIN
..
}IP
- J \.- IP
.
Location of
Tender Point
..-l._
These tender points are located on the capsule to the proximal. middle. or distal
interphalangeal joints. Pressure is applied over the tender point toward the center of
the finger.
c+
Position of
The therapist folds the more distal phalanx over the tender point. and rotation and
Treatment
II
LOWER QUADRANT
Practitioner
Dates
. Extremely sensitive
\
Xl.
e . Very sensitive
/-
- Right
- Moderately sensitive
+
Left
- Most sensitive
- No tenderness
(; - Treatment
130_ All
131. ABL2
XlI.
00000
00000
132. AL2
133. AL3
00000
00000
134. AL4
00000
00000
140.SPB
00000
00000
00000
150.PL3-1
135. AL5
00000
00000
00000
00000
136.IL
137.GMI
XIII.
00000
00000
138.SAR
139.TFL
141.IPB
00000
00000
142.LPB
143.ADD
00000
00000
144.PLl
145.PL2
146.PL3
XIV.
00000
00000
00000
147.PL4
148.PL5
149.QL
151.PL4-1
152.UPL5
00000
00000
00000
153.LPL5
00000
00000
00000
160.GME
00000
00000
154.SSI
155.MSI
XV.
00000
00000
156. lSI
157.GEM
00000
00000
158. PRM
159.PRL
00000
00000
161.ITB
162.PSI
163. PS2
XVI.
00000
00000
164.PS3
165.PS4
00000
00000
166.PS5
00000
00000
00000
174.PES
00000
00000
00000
I S4. FDL
00000
00000
00000
00000
00000
00000
200.PCN3
167.COX
00000
00000
168. PAT
169. PTE
170.MK
XVII.
00000
00000
00000
171.LK
172.MH
173. LH
175.ACL
176.PCL
00000
00000
00000
177.POP
00000
00000
00000
00000
00000
00000
IS7. EDL
00000
00000
00000
00000
00000
00000
00000
00000
00000
206.PMTI
17S. MAN
179.LAN
180.AAN
XVlll.
00000
00000
00000
lSI. TAL
182.PAN
183.TBP
185.TBA
186.PER
ISS. MCA
189. LCA
190. PCA
191. DCB
192.PCB
193.DNV
142
00000
00000
00000
00000
00000
00000
194.PNV
195.DCNI
196.DCN2
197.DCN3
19S.PCNI
199.PCN2
201.DMTl
202.DMT2
203.DMT3
204.DMT4
205.DMT5
207.PMT2
208.PMTJ
209.PMT4
210.PMT5
00000
00000
00000
. 00000
00000
00000
LUMB A R S PINE, P E LV I S, AN D
H I P
Low back pam " a lead 109 cause of dlSab,"ty and lost pro
ductivity in our IDCicry. The lumbar spine has been the sub
ment mclude low back pain, scoliosis, hip and lower lllnh
dysmenorrhea.
11,e major focus of soft tissue therapy has been the pos
, TREATMENT
use
of extension, which IS
or
treated
III
the anterior aspect of the pelvis. The tender points for the
second, third, and fourth lumbar are located on the P""lS ilS
the femur.
Involved muscles, and the leg, are used for added leverage.
points are associated with the levator am, and lesions are
143
ANT E R IO R
L U MB A R
lliacus --\<H\\
144
S PIN E
Tender Points
ALI
AL2
.rla!!_ AL3
- AL4
ASIS
SAR
GMI
(landmark)
ADD
"I
Location of
Tender Point
Position of
Treatment
Iliacus
AL3
AL4
SPB
LPB
ALS
IPB
This tender point is located medial to the anterior superior iliac spine. Pressure is
applied posteriorly just medial to the ASIS and then laterally on the ASIS.
I . The patient is supine. The therapist stands on the side of the tender point. The
patient's hips are flexed markedly, rotated to the side of the tender point, and lat
erally flexed toward or away from the tender point side.
2. The head of the table may be raised, pillows placed under the patient's pelvis, or a
physical therapy ball used to support the legs to facilitate the treatment (see
photo above right).
145
CHAPTER 6
146
Treatment Procedures
IL
ASIS
SAR?
GMI
Psoas
(landmark)
ADD
Location of
Tender Point
Position of
Treatment
AL4
,..--,..--+--- SPB
'----;-- LPB
----f-- ALS
==t-- 1PB
This tender point is located in the abdominal area approximately 5 em (2 in.) lateral
and slightly inferior to the umbilicus on the lateral margin of the rectus abdominus.
The patient is supine. The therapist stands on the side of the tender point. The ther
apist flexes the hips to 90 and rotates the hips approximately 60 toward the tender point side. and laterally flexes the hips away from the tender point side by
elevating the feet. The head of the table may be raised. or pillows placed under the
patient's pelvis.
Treatmem Procedures
IL """f--.
ASIS
(landmark)
SAR?
GMI
ADD
Location of
Tender Point
Position of
Treatment
CHAPTER 6
147
Iliopsoas
AL4
--+-- SPB
--+L- PB
ALS
---:--- IPB
r---"';-
This tender point is located on the medial surface of the anterior inferior iliac spine.
The hips may be flexed 45 to facilitate location of the point. Pressure is applied pos
teriorly just medial to the AilS, then laterally on the bone.
The patient is supine. The therapist stands on the opposite side of the tender point.
The therapist flexes the patient's hips to approximately 90, rotates the hips approxi
mately 60 away from the tender point side, and allows the feet to drop toward the
floor to produce lateral flexion away from the tender point side. The head of the
table may be raised, or pillows placed under the patient's pelvis.
CHAPTER 6
148
Treatment Procedures
IL
ASIS
(landmark)
SAR?
GMI
AL4
""""'S-1-- PS
'----,,- LPB
-:"'-' -'--- ALS
'--IPS
-
ADD
l
Location of
Tender Point
Position of
Treatment
Iliopsoas
':--
The tender point for AL3 is located on the lateral aspect of the anterior inferior iliac
spine. The hips may be flexed 45 to facilitate location of the point. Pressure is
applied posteriorly just lateral to the AilS, then medially on the bone. The tender
point for AL4 is located on the inferior aspect of the anterior inferior iliac spine. The
hips may be flexed 45 to facilitate location of the point. Pressure is applied posteri
orly just inferior to the AilS, then superiorly on the bone.
The patient lies supine. The therapist stands on the side opposite the tender pOint.
The therapist flexes the patient's hips to approximately 70 to 90 and rests the
patient's legs on the therapist' thighs or on a physical therapy ball. The hips are later
ally flexed away from the tender point side by pulling the legs toward the therapist.
Fine-tuning is added by slightly rotating the hips toward or away from the tender
point side.
Treatment ProcedHres
CHAPTER 6
149
Iliopsoas
IL
ASIS
SAR -/
GMI
(landmark)
ADD
Location of
Tender Point
Position of
Treatment
AL4
SPB
LPB
ALS
IPB
This tender point is located on the anterior surface of the pubic bone approximately
1.5 em (0.6 in.) lateral to the symphysis pubis. Pressure is applied posteriorly.
The patient lies supine with the therapist standing on the side of the tender point.
The therapist flexes the hips to approximately 900 to 1200 and rotates the hips
toward and laterally flexed away from the tender point side.
ANT E RIO R
P E L V I S AN D HI P
GMI --#J.
Anterior View
TFl
Lateral View
1 50
Tender Points
IL
ASIS
(landmark)
GMI
ALl
AL4
SPB
LPB
ADD
IPB
SAR
ALS
Location of
Tender Point
Position of
Treatment
IL
Gluteus
minimus and
medius
Tensor
fasciae
latae
Iliopsoas
Rectus
femoris
This tender point is located approximately 3 cm ( 1.2 in.) medial to the ASIS and
deep in the iliac fossa. Pressure is applied posteriorly and laterally.
The patient lies supine with the ankles supported on the therapist'S thighs (see photo
above left) or on a physical therapy ball (see photo above right) or chair. The therapist
stands on the tender point side and produces extreme flexion and external rotation
of both hips. Rotation toward the tender point side may be added to fine-tune.
151
152
CHAPTER 6
Treannen! Procedures
ASIS
(landmark)
SAR
GMI
GMI
....
GMI
-;;:;
ADD
1
Location of
Tender Point
Position of
Treatment
This tender point is located approximately I cm (0.4 in.) lateral to the anterior infe
rior iliac spine. The hips may be flexed 45 to facilitate location of the point. Pressure
is applied posteriorly.
The patient is supine. The therapist stands on the side of the tender point. The ther
apist flexes the hip markedly (approximately 130) with no abduction or rotation.
Treatment Procedures
CHAPTER 6
153
IL
ASIS
(landmark)
SAR?
GMI
ADD
1
------'
Location of
Tender Point
Position of
Treatment
This tender point is located approximately 2 em (0.8 in.) lateral to the AilS. The hips
may be flexed 45 to facilitate location of the point. Pressure is applied posteriorly.
The patient is supine with the therapist standing on the side of the tender point. The
therapist flexes the hip to 90 and adds moderate abduction and external rotation.
154
Treatment Procedures
CHAPTER 6
TFL
GME
..,
TFL
ITB
Location of
Tender Point
Position of
Treatment
Lateral and inferior to the ASIS and superior to the greater trochanter. on the ante
rior border of the tensor fascia lata. Pressure is applied posteriorly and medially.
The patient lies supine. The therapist stands on the side of the tender point. The
therapist then flexes the hip to 90 and adds moderate abduction and marked
internal rotation by pulling the ipsilateral foot laterally.
Treatment Procedures
CHAPTER 6
l55
Pubococcygeus
IL
ASIS
(landmark)
SAR
GMI
ADD
____
Tender Point
Position of
Location of
Treatment
AL4
--4-- SPS
"'"----::---LPS
r-':
'- ALS
_--".'--- IPS
SPB
Puborectalis
Pubococcygeus Levator Ani
Iliococcygeus
This tender point is located on the superior aspect of the lateral ramus of the pubis
approximately 2 cm (0.8 in.) lateral to the pubic symphysis. Pressure is applied poste
riorly above the pubic bone and then inferiorly.
The patient is supine. with the therapist standing on the same side as the tender
point. The therapist flexes the hip to 900 to 1200 with no abduction or rotation.
156
CiIAPTER 6
Treatment Procedures
ASIS
(landmark)
SAR
GMI
-/
Puborecta lis
Pubococcygeus LevatorAni
Iliococcygeus
ADD
lliococcygeus
Location of
Tender Point
This tender point is located on the medial surface of the descending ramus of the
pubis. Pressure is applied superiorly and laterally.
Position of
Treatment
The patient is supine, and the therapist stands on the tender point side. The thera
pist flexes, abducts, and externally rotates the affected hip.
Treatment Procedures
CHAPTER 6
157
_
ILi--+::-ASIS
(landmark)
SAR
GM I
-?
AOO ---.......
Location of
Tender Point
Position of
Treatment
AL4
o------i-- SPB
'----I- LPB
r--!.-- ALS
----i- IPB
This tender point is located on the lateral surface of the body of the pubic bone on
the medial margin of the obturator foramen. Pressure is applied medially.
The patient is supine. The therapist stands on the same side as the tender point and
flexes the patient's hips to approximately 90. The therapist places his or her foot on
the table and rests the patient's legs on the therapist's thigh. The unaffected leg is
crossed over the affected leg. The therapist then uses the affected leg to internally or
externally rotate the femur.
Note:
A physical therapy ball or a chair may be used to support the patient's legs.
158
CHAPTER 6
Treatment Procedures
IL
ASIS
(landmark)
SAR
GMI
ADD
Location of
Tender Point
Position of
Treatment
AL4
"-:---:lI!-- SPS
"---'+--- LPB
e--'::';-_ ALS
"",*
--
-- IPS
This tender point is located on the anterolateral margin of the pubic bone and the
descending ramus of the pubis (pressure applied posteromedially) or on the lower
third of the adductor muscle belly on the medial aspect of the thigh (not shown).
The patient is supine with the therapist standing on the side opposite the tender
point. The therapist reaches across the patient and grasps the patient's distal tibia
(extended knee) or the lateral aspect of the involved knee (flexed knee) and adducts
it by pulling the leg medially.
P 0 S T E RIO R
L U MB A R
S PIN E
Tender Fbints
Posterior View
G luteus medius
PL3-1 --#..
PL4-1 --li'qW,-,)
Gluteus
maximus ---'"""
(cut)
Tensor
-,1,,..1- fasciae
latae
Iliotibial --I---l+
tract
Lateral View
159
QL {
PS3PS2
PS4PSS
151
Location of
Tender Point
Position of
Treatment
-PLI
-PL2
-pu
_ L4
PSIUPLS
....SSILPLS
PL3-1
_PL4-1
-MSI
_PRM
These tender points are located on the lateral aspect of the spinous processes
(pressure applied medially), in the paraspinal sulcus or on the posterior aspect of the
transverse processes (pressure applied anteriorly).
The patient lies prone. The head of the table is raised, or pillows are placed under
the patient's chest. The therapist stands on the side opposite the tender point. The
therapist grasps the anterior aspect of the pelvis on the tender point side and pulls
it posteriorly to create rotation of the pelvis of approximately 30 to 45.
Note:
160
Rotatores
Tender points closer to the midline of the body are treated with more pure
extension; lateral tender points are treated with the addition of more lateral
flexion and rotation.
Treatment Procedures
CHAPTER 6
16 1
PS2
PS3
PS'I
-PlI
-Pl2
-PLl
-PL4
-Pt.5
=====:i
PSs------'
ISI ------..,,,.,
Location of
Tender Point
Position of
Treatment
These tender points are located on the lateral aspect of the transverse processes
from L I to L5. Pressure is applied anteriorly and then medially.
I . The patient is prone with the head of the table raised or a pillow placed under
the patient's chest. The therapist stands on the side opposite the tender point and
reaches across to grasp the ilium of the affected side. The therapist then instructs
the patient to flex and abduct the ipsilateral hip to approximately 45 (see photo
above left).
2. The patient is prone with the trunk laterally flexed toward the tender point side.
The therapist stands on the side of the tender point. The therapist places his
or her knee on the table and rests the patient's affected leg on the therapist's
thigh. The patient's hip is extended and abducted, and slight rotation is used to
fine-tune (see photo above center).
3. The patient is lateral recumbent on the unaffected side with the hips and knees
flexed to approximately 90. The therapist stands behind the patient and grasps
the ankles and lifts them to induce moderate side bending of the torso. The
patient's shoulder on the affected side is protracted or retracted to fine-tune (see
photo above right).
162
CHAPTER 6
Treatment Procedures
======1
Multifidus, Rotatores
PS 2
PS3
PS4
PS5
IS I -----::"'"
---
Location of
Tender Point
Position of
Treatment
UPLS
LPl5
....
.SSI
PU.I
.-PL41
e___MSI
e___ PRM
PRL
GEM
This tender point is located approximately 3 cm ( 1.2 in.) below the crest of the ilium
and 7 cm (2.8 in.) lateral to the posterior superior iliac spine. Pressure is applied
anteriorly and medially.
The patient lies prone while the therapist stands on the same side (see photo above
left) or the opposite side (see photo above right) of the tender point. The therapist
then extends the thigh on the affected side and supports it with the therapist's leg
or a pillow. The therapist then moderately adducts and markedly externally rotates
the thigh.
Treatment Procedures
163
CHAPTER 6
QL
PS2
_
-
-PLI
-Pl2
-PLJ
-PL4
151 ---4
PL41
PSI
PSPSS3 =======1
PS4
Gluteus medius
551
PL3-1
"
.-PL4-1
.--
Gluteus
maximus
(cut)
Tensor
fasciae
latae
PL4-1
Iliotibial --1-4'1-
tract
"I
Location of
Tender Point
Position of
Treatment
This tender point is located approximately 4 cm (1.6 in.) below the crest of the ilium
and just posterior to the tensor fascia lata.
The patient lies prone while the therapist stands on the same side of the tender
point. The therapist then extends the thigh on the affected side and supports it with
the therapist's leg or a pillow. The therapist then slightly adduces and moderately
externally rotates the thigh.
Note: Pl31
and
PL41
HAI'TER 6
164
Treannenr PTocedlTes
---
PS2
PS3
PS4
PS5
lSI
-PLl
-Pl3
-Pl4
PSI
LPl5
SSI
PL3-1
.-PL4-1
MSI
PRM
==== -PL5
location of
Tender Point
-PLI
Position of
Treatment
"
This tender point is located on the superior medial surface of the posterior supe
rior iliac spine. Pressure is applied inferiorly and laterally.
The patient lies prone with the therapist standing on the opposite or same side of
tenderness. The therapist extends the hip on the affected side and supports the
patient's leg on the therapist's thigh. The therapist then slightly adducts the patient's
leg and adds mild external rotation to fine-tune the position.
Note:
Treatment Procedures
QL
PS 2
PS3
PS4
- e e e-PLI
- -pu
- -PlJ
- e e e -Pl4
- eee
CIIAPTER 6
165
Iliopsoas, SI Ligaments
PSI
====:=
s
"'
SSI
...-P-.- L3-1
e-PL4-1
PS5
_MSI
ISI ---
LPLS
"I
Location of
Tender Point
Position of
Treatment
This tender point is located approximately 1.5 cm (0.6 in.) inferior to the posterior
superior iliac spine in the sacral notch. Pressure is applied anteriorly.
I.
The patient lies prone. The therapist. seated on the tender point side. asks the
patient to move to that side of the table so that the affected leg can be dropped
off the edge of the table. The therapist then grasps the ipsilateral leg. flexes the
hip to approximately 90. and adds slight adduction and internal rotation. The
opposite ilium may be retracted slightly to fine-tune.
2. The patient lies prone. The therapist stands on the opposite side of the tender
point and grasps the ilium. at the level of the ASIS. on the side of the tender
point. The patient is instructed to flex and abduct the leg on the affected side. The
ilium is then retracted and rotated toward the tender point side.
Note:
P 0 S T E R IO R P E L V I S AN D H IP Tender
SSI
GME
Gluteus
minimus
/; .,-"-+- MSI
;;:;5--;- Piriformis
", .q- PRM
Superior
gemellus
PRL
Quadratus
femoris
Obturator
internus
Posterior View
.---I--".l'!f- ITS
166
Lateral View
Points
-Pll
-PLI
-PL3
-PL4
PSI
UPLS
LPLS
PS2
PS3 :====::::jJ 'SSI
PL3-1
PS4
Gluteus Medius
PS5------'
ISI -------::"""
PL4-1
Gluteus
",.y..- minimus
----i't- Piriformis
Superior
'---!-.;) gemell
us
internus
Location of
Tender Point
Position of
Treatment
Inferior
gemellus
Quadratus
femoris
This tender point is located on the lateral aspect of the posterior superior iliac
spine (PSIS). Pressure is applied anteriorly approximately 3 cm ( 1.2 in.) lateral to the
PSIS and then medially.
The patient is prone, and the therapist stands on the side of the tender point. The
therapist places his or her foot or knee on the table and supports the patient'S
extended thigh on the therapist's thigh. The hip is moderately extended and slightly
abducted.
167
CHAPTER 6
168
Treatment Procedures
PSI
UPL5
LPL5
PS2 :====3 "551
PS3
PS4
PSS
151-----:
PL3-1
PL4-1
Gluteus Minimus
Gluteus
minimus
t-."---f-- MSI
""'--""'!--:fl-- Pirifor mis
'-r----) gemel
Superior
lus
Quadratus
femoris
location of
Tender Point
Position of
Treatment
This tender point is located in the center of the buttocks. Pressure is applied anteri
orly and medially.
The patient is prone, and the therapist stands on the side of the tender point. The
therapist grasps the patient's leg and markedly abducts the thigh. The therapist fine
tunes the position with a slight amount of flexion/extension or internal/external
rotation.
Treatment Procedures
PS4
151
169
-P\.3
-PLI
-Pl2
PSILPLS
UPLS
-P1.4
-P\.5
=-====
PS5-----'
PS2
PS3
HAPTER 6
"
551
PL3-1
---7"lI
Location of
Tender Point
Position of
Treatment
This tender point is located in a line along the sacrotuberous ligament from the
ischial tuberosity to the posterior aspect of the inferior lateral angle of the sacrum.
Pressure is applied anteriorly and laterally.
The patient is prone with the therapist on the side opposite the tender point. The
therapist reaches across to grasp the leg on the involved side and extend. adduct.
and externally rotate it across the uninvolved leg. This position may be performed in
the lateral recumbent posture with the involved side up.
170
Treatment Procedures
CHAPTER 6
-QL{ --
PS2
PS3
PS4
PSS
-PI.I
-PLl
-PlJ
-Pl4
-PlS
151
Location of
Tender Point
Position of
Treatment
This tender point is located on a line from the lateral inferior surface of the ischial
tuberosity to the medial aspect of the posterior surface of the greater trochanter of
the femur. This is along the gluteal fold. Pressure is applied anteriorly.
I . The patient is prone. The therapist stands on the opposite side of the tender
point, places the patient's ankle in the therapist's axilla, and grasps the patient's
flexed knee. The therapist extends, adducts, and externally rotates the hip. (See
photo above left.)
2. The therapist stands on the same side as the tender point and supports the
patient's thigh on the therapist's thigh (which is resting on the table) and pro
duces extension, adduction, and external rotation. (See photo above right.)
Treatment Procedures
CHAPTER 6
171
-{ ---
QL
PS2
PS3
PS5
151
Tender Point
(PRM)
Location of
Tender Point
...
PS4
Location of
Pll
-Pll
-P\.3
-PL4
PSI
UPL5
LPLS
551
PL3-1
.-PL4-1
____M
__ 51
PRM
PRl
PRM
PRL
This tender point is found in the belly of the piriformis approximately halfway
between the inferior lateral angle of the sacrum and the greater trochanter. Pressure
is applied anteriorly.
This tender point is located on the posterior, superior, lateral surface of the greater
trochanter. Pressure is applied anteriorly.
(PRL)
Position of
Treatment
I . PRM: The patient is prone, and the therapist is seated on the tender point side.
The ipsilateral leg is suspended off the table with the bent knee resting on the
therapist's thigh. The hip is flexed to approximately 60 to 90 and abducted.
Internal/external rotation is used to fine-tune the position. (See photo above left.)
2. PRL: The patient is prone, and the therapist stands on the tender point side. The
ipsilateral thigh of the patient is extended and abducted and supported on the
therapist's thigh, which is resting on the table. The therapist brings the patient's
thigh as close as possible to the therapist's hip and then rolls the patient's thigh
down toward the table to produce marked external rotation. (See photo above
right.) (This treatment may also be used for PRM.)
Note:
172
Ci IAfYrER 6
Treacment Procedures
GME
GME
__-.
Ifh-TFL
ITS
Location of
Tender Point
Position of
Treatment
These tender points are located on a line approximately I em (0.4 in.) inferior to
the iliac crest and 3 to 5 em ( 1. 2 to 2 in.) on either side of the midaxillary line. Pres
sure is applied medially.
The patient lies prone, and the therapist stands on the same side as the tender
point. The therapist extends and abducts the hip and supports the patient's leg on
the therapist's thigh. The hip is pOSitioned in marked external rotation for tender
points located posterior to the midaxillary line (see photo above left) and in internal
rotation for those located anterior to the midaxillary line (see photo above right).
Treatment Procedures
CIIAPTER 6
173
GME ---...
..
.....,
..
"r-- TFL
hl---fjl- ITB
ITB
Location of
Tender Point
Position of
Treatment
These tender points are located on the iliotibial band along the lateral aspect of the
thigh on the midaxillary line. Pressure is applied medially.
The patient may be supine or prone. The therapist stands on the side of the tender
point, grasps the patient's leg, and produces marked hip abduction and slight hip
flexion with internal or external rotation to fine-tune the position.
P 0 S T E R IO R
S AC RU M Tender
Points
----- 2
;------- 3
4
Posterior View
Pubis
Puborecta lis
Pubococcygeus Levator Ani
Iliococcygeus
Obturator internus
=-----JT- Ischium
Piriformis
Coccygeus
Superior View
174
Posterior Sacrum
162. Posterior First Sacral (PS1 )
QL{
PS2
PS3
PS4
PSS
-P1.1
-Pll
-P1.4
-PLS
PU
Levator Ani
Short posterior
sacroiliac ligaments
PSI
s::s:/
151
Long
posterior
sacroiliac
ligament
Sacrotuberous
ligament
Sacrococcygeal
ligaments
Location of
Tender Point
Position of
Treatment
Tendon of
biceps femoris
This tender point is located in the sacral sulcus. medial and slightly superior to the
PSIS. Pressure is applied anteriorly.
The patient is prone. The therapist applies an anterior pressure on the inferior
lateral angle opposite the tender point side. resulting in rotation around an oblique
axis.
175
176
CHAPTER 6
Trearment PrOCedtlTeS
Posterior Sacrum
QL{
Levator Ani
-Pl.1
-PL2
-PlS
PlJ
Pl.4
PS3
PS4
151
Location of
Tender Point
Position of
Treatment
This tender point is located on the midline of the sacrum between the first and
second sacral tubercles. Pressure is applied anteriorly.
The patient is prone.The therapist applies an anterior pressure on the sacral apex in
the midline. producing rotation around a transverse axis.
Treatment Procedures
QL
PS2
CHAPTER 6
177
Levator Ani
-PLI
P1.2
PLJ
-PL
-PLS
PSS
151
"I
Location of
Tender Point
Position of
Treatment
This tender point is located in the midline of the sacrum between the second and
third sacral tubercles. Pressure is applied anteriorly.
The patient is prone. The therapist applies an anterior pressure on the apex (or
occasionally the base) of the sacrum in the midline. resulting in rotation around a
transverse axis. Alternatively. the patient may be placed in sacral extension by raising
the head end of the table and the foot end of the table or by using pillows to sup
port the patient's trunk and lower limbs in extension. with the third sacral segment
as the fulcrum.
CHAPTER 6
178
Treatment Procedures
Posterior Sacrum
QL{
PS2
PS3
Levator Ani
...-
..
,-
-PLl
-
Pl."
-
-PLS
PSS
lSI
Location of
Tender Point
Position of
Treatment
This tender point is located in the midline of the sacrum just above the sacral hiatus.
Pressure is applied anteriorly.
The patient is prone. The therapist applies an anterior pressure on the sacral base in
the midline. producing rotation around a transverse axis.
Treatment Procedures
QL
PS2
PSJ
f>S.4
CIIAf'fER 6
179
Levator Ani
-PI.I
-pu
-pu
-PL4
-PLS
151
Location of
Tender Point
Position of
Treatment
This tender point is located approximately I cm (0.4 in.) superior and medial to the
inferior lateral angle of the sacrum. Pressure is applied anteriorly.
The patient is prone. The therapist applies an anterior pressure on the sacral base
on the side opposite the tender point, resulting in rotation around an oblique axis.
CHAPTER 6
180
Treatment Procedures
Posterior Sacrum
QL{
PS2
PS3
PS4
PSS
151
cox
location of
Tender Point
Position of
Treatment
This tender point is located on the inferior or lateral edges of the coccyx. Pressure
is applied superiorly or medially.
The patient is prone. The therapist applies an anterior pressure on the sacral apex in
the midline. Rotation or lateral flexion of the sacrum, usually toward the tender
point side, may be added to fine-tune the position.
DMT2,3
7
The Use of Positi onal Release
Therapy in Clinical Practice
Can Po itional Release
221
Other Modalitie
The Use of Reality Checks
222
222
222
223
223
223
225
225
225
224
Treatment Session?
Has Pain?
What Happens If Pain or Other
Conflicting Points?
224
Strain lnjurie ?
224
225
225
or
221
222
CHAPTER 7
past or from the present injury, the tissues may have become
of,motion test (the patient lifts his arm over his head while
what the patient can expect during and after the treatment
or
sacral spring
and down stairs) can also be used. If a patient has low back
and what they should feel. Some patients have no idea what
CIIAPTER 7
223
he required.
rior aspects llf the neck. The practitioner may find that an
111
third lumbar.
(p. 152). In this situation, these two points are In close prox#
patient may need 120 degrees of flexion to shut that point off.
Therefore It
IS
ahle anJ rdaxeJ whtle betng trcateJ, anJ If there IS any paIn
panent's body knows mure about its needs than the thera
the weight with only hIS hanus or arms. lie should Imng the
weight in close to his l:x"Kly and usc the larger muscle groups,
there will he a position thlt will shut the tender point off
sues more. Then she shoulu add rotation to the left and to
smk the fingers into the tlS.!lUC, sprc<1C..llIlg some of the fat our
IIlg to [he left and right and then fine tune the position,
III
thIS book.
If the lender poinr returns Immediately after treatment,
the height of [he tahle may vary. I[ " imperative that [he
CHAPTER 7
224
of symptoms.
associated
with
the
production
of
palO.
therapist should extend the elbows, lean back, and use her
surgical Intervention
111
rare cases.
care resources.
points in the body, bur these are the ones that are explained
In these cases, the general rules should be used t<l treat any
til
other locations.
CHAPTER 7
225
than a few minutes. The patient may also feel heat, vibra,
been in spasm for several years and that docs not fully
sure the patient that these sensations are part of the release
been completed.
strenuous
attention, if necessary.
8
New Horizons
Listen ing
to
the Tissues-Treating
the Dysfunction
227
228
228
as
of dysfunction.
will teli you that when confronted with flames, the extin
sues and joints above and below the cast that become
fuel is feeding the flames, this should be turned off first. This
the dysfunction.
227
228
CHAPTER 8
New Horizons
pies are necessary to prepare the tissues so that they can tol
of physical fitness).
sisting dysfunction.
New Horizons
We are beginning to appreciate the dynamic, selfregulating,
CHAPTER 8
229
few minutes. This will reveal the hidden truth behind the
as
copied and used for each patient. and the tcnder point body
wear this book out. By the time that occurs, you may find
Appendix
Positional Release Therapy Scanning Evaluation
232
234
236
239
242
244
250
Patient's name:
\
I.
Extremely sensitive
e, Very sensitive
Q. Moderately sensitive
Right
Left
Most sensitive
No tenderness
Treatment
Cranium (p.45)
I. OM
2. 0CC
3. PSB
4. LAM
5. SH
II.
20. ACI
22. AC3
III.
6. DG
7. MPT
8. LPT
9. MAS
10. MAX
00000
00000
00000
00000
00000
11. NAS
12. SO
13. FR
14. SAG
15. LSB
00000
00000
00000
00000
00000
16. AT
17. PT
18. TPA
19. TPP
00000
00000
00000
00000
00000
00000
00000
00000
23. AC4
24. AC5
25. AC6
00000
00000
00000
26. AC7
00000
00000
00000
37. PC6
00000
00000
00000
46. AT7
27. AC8
28. AMC
00000
00000
00000
29. LCI
30. LC
30. LC
00000
00000
00000
IV.
00000
00000
00000
00000
00000
00000
00000
00000
34. PC3
35. PC4
36. PCS
38. PC7
39. PC8
00000
00000
00000
00000
00000
00000
00000
00000
00000
43. AT4
44. ATS
45. AT6
47. AT8
48. AT9
00000
00000
00000
49. ATIO
50. ATII
51. ATl2
00000
00000
00000
V.
52. ARI
53. AR2
54. AR3
55. AR4
56. AR5
00000
00000
00000
00000
00000
57. AR6
58. AR7
59. AR8
60. AR9
61. ARlO
00000
00000
00000
00000
00000
62. MRJ
00000
00000
134. AL4
00000
00000
140. SPB
00000
00000
00000
174. PES
63. MR4
64. MRS
65. MR6
66. MR7
00000
00000
00000
00000
00000
67. MR8
68. MR 9
69. MRIO
00000
00000
00000
00000
00000
VI.
130. ALI
131. ABU
VII.
137. GMI
VIII.
00000
00000
132. AU
133. AU
135. AL5
00000
00000
00000
00000
136.IL
00000
00000
138. SAR
139. TIL
141. IPB
00000
00000
142. LPB
00000
00000
00000
177. POP
143. ADD
00000
00000
168. PAT
169. PTE
170. MK
232
Dates:
00000
00000
00000
171.LK
In.MH
173. L H
175. ACL
176. PCL
00000
00000
00000
IX.
X.
189. LCA
190. PCA
191. DCB
192. PCB
193. DNV
95. SCL
96. AAC
97. SSL
98. BLH
114. LEP
123. CET
71. PTZ
n. PT3
83. PR2
84. PR3
144. PLl
146. PL3
00000
00000
00000
00000
00000
00000
00000
00000
00000
194.PNV
195.DCNI
196. DCN2
197. DCN3
198. PCNI
199.PCN2
00000
00000
00000
00000
00000
00000
200. PCN3
201. DMTl
202.DMTZ
203. DMT3
204. DMT4
205.DMT5
00000
00000
00000
00000
00000
00000
206.PMTl
00000
00000
00000
00000
00000
00000
207.PMTZ
208.PMT3
209.PMT4
210.PMT5
00000
00000
00000
00000
00000
99. SUB
100. SER
101. MHU
102. BSH
103. PMA
00000
00000
00000
00000
00000
104. PMI
105. LD
106. PAC
107. SSM
108. MSC
00000
00000
00000
00000
00000
109. ISS
110. ISM
I I I. lSI
112. TMA
113. TMl
00000
00000
00000
00000
00000
00000
00000
116. RHS
117. RHP
00000
00000
118. MCD
119. LCD
00000
00000
120. MOL
121. LOL
00000
00000
00000
00000
124. PWR
125. DWR
00000
00000
126. CMI
127. PIN
00000
00000
128. DIN
129. IP
00000
00000
00000
00000
00000
73. PT4
74. PT5
75. PT6
00000
00000
00000
76. PT7
77. PT8
78. PT9
79. PTlO
00000
00000
00000
80. PTlI
00000
00000
00000
92. PRII
81. PTl2
00000
00000
00000
00000
00000
00000
85. PR4
86. PRS
87. PR6
00000
00000
00000
88. PR7
89. PR8
90. PR9
91. PR10
93. PRI2
00000
00000
00000
00000
00000
00000
147. PL4
148.PL5
149.QL
00000
00000
00000
150. PL31
151. PL41
152. UPL5
00000
00000
00000
153.LPL5
00000
00000
00000
160.GME
00000
00000
XVIII.
187.EDL
XVII.
186. PER
00000
00000
00000
XV I.
185. TBA
XV.
184. FDL
XIV.
183.TBP
00000
00000
00000
XIII.
182.PAN
XII.
181.TAL
Foot (p.205)
188.MCA
Xl.
00000
00000
00000
00000
00000
156. lSI
157. GEM
00000
00000
159.PRL
00000
00000
167.COX
158. PRM
00000
00000
161. ITB
00000
00000
164. PS3
165.PS4
166. PS5
00000
00000
00000
00000
233
N
'"
...
--.
t
.I'
.-n-__f\ '<
15 .LSB
2S . A M
16.AT
5.SH
29.LCI
4 0.ATI
30.LC
41.AT2
20.ACI
42ATJ
43.AH
Lateral
'
J\
21.AC 2
22.AC3
23.A C 4
24.A C 5
2S.AC6
27ACS
12.S0
--t:;--.
----1,f-\-l
I O.MAX '-r'e
9.MAS - ".",,,',,,..--u
55.AR4
57.AR6
'\:.-
I 32.AL2
--I33.AL3
IH.AL4
4LAM
3.PSB
Z
---1
73.PH
74.P T5
75.PT6
c:P
76 . P Tl
o
o
-<
77 . P TS
7S.PT9
79.PTIO
SO.PT I I
SI. PTI2
()
I
:::u
---1
160.GME
154 .sSI
155.MSI
(J)
15S.PRM
2.0 C C
7.MPT
Posterior
:::u
71.PT2
72.PTJ
162.PSI
130.ALI 150.PL 3- 1
\J
70.PTI
149.QL
S3.-93.
( '01":j !WI),
I.OM
.J>
61.ARIO
PI f.'I1; o
nr
-{
1i0l;r-
60.AR9
5 1.ATI2
1t''<Q''0{
59.ARS
0-
5 0.ATII
/\
iil
5S.AR7
49.ATIO
14.SAG
, F
56.AR5
47.ATS
Anterior
"t::-r
:\l
54.AR3
cA!n-
4S.AT9
=--=::::
I
S2.PRI
53.AR2
46.AT7
II.NAS
<
26.AC 7
52.ARI
45.AT6
---lv'r-
C 2-6
:: 0
lL
44.AT5
13.FR
Z
o
32.PCI-E
e-+- 13.FR
17.PT
---1
Cranial Points
140.
141.IPB
159.PRL
I 35.AL5
142.LPB
SPB
I 64.PS3
6. D G
166.PS5
Anterior
165 . P S4
Posterior
:/,
143.ADD
-;
m
Z
0
m
;IJ
17S.ACl
"
106.PAC
I 7 6PCl
173.l H
107.s 5M
109.15 5
I72.M H
I 13.TMI-r1I'
IIO.l5M
Lateral
I 77.PO P
94.TRA
9S.S
Cl
96 . A A
104.PMI
102.B SH
----r-r-T
II I.ISI
9B.Bl H
-=::t::t=-:
112.TMA
103.P MA
IB3.TBP
Posterior
G:ll
"---'\
IBO.AAN
1 6B.PAT
206.207.
209.210
'1"
PMH.S
t-t-rI-t-I--
120M
. Ol
121.l0l
170M
. K--
I
n
0
z
--1
201.202 .
PMTI.2
I 94.PNV
IB7E
. Dl
114.l EP
IIBM
. CD
116.R H S
119.lCD
117.R H P
DMH.S
PCNI .2.3
IBS.TBA
t" t
IIS . M EP
DMTI.2
204.205.
19B-2oo.
I 92.PCB
Anterior
190P
. C
S --
- -IB6.PE R
IB2.PAN
Posterior
n
I
Elbow/Wrist/Hand
Tender Points
N
'-'
0
-<
Medial
Anterior
IH.P E
V>
100.sER
I84.FDl
169.P TE
tp
-;
10S.lD
Z
-;
Plantar
Dorsal
Dorsal
Palmar
236
ApPENDIX
Anatomic Reference
Acromioclavicular joint
Adductor hallucis
Adductors
Anconeus
Anterior cruciate ligament
Biceps
Brachialis
Coccygeus
Common extensor tendon
Common flexor [cndon
Coracoacromial ligamenr
Coron",1 suture
Cuboid (bone)
Cuneiform (bones)
Deltoid anterior
Deltoid ligament
Diaphragm
Digastric
Dorsal calcaneocuboid ligament
Dorsal cuneounavicular ligament
Dorsal interossei
Extensor digitorum longus
AAC, PAC
PMTl
ADD
LOL,MOL
ACL
BLH, BSH
LCD,MCD
ISI,COX
CET
CFT
AAC
FR
DCB, PCB
DCN 1-3, PCN 1-3
AAC
MAN
AT7-9
DG
DCB
DCN 1-3
DIN, DMT2,3, DMT4,5
AAN, EDL
DMT2,3, DMT4,5
AAN,DM T l
PMT4,5
PCA, DMT2,3, DMT 4,5
FDL
CMI
FR
SO
PAN
GEM
MHU
GME,SSI
GMI,MSI
LH
MH
IL, ALI
IPB, LPL5
AL2-5, LPL5
ITB
ISS,ISM,151
MRJ-IO
ATI-6, AR3-10
IP
PC3-7
PLI-5
PTI-12
LAM,acC
LK
Page
108,118
217
158
IJ2
190
110,114
131
169,180
135
134
108
57
208, 209
212,213
108
194
88
50
208
212
140,215,216
196,203,215,216
196,214
219
207,215,216
200
138
57
56
198
170
113
172, 167
152, 168
188
187
151, 145
156,165
147,165
173
121,122,123
94
86, 87, 93
141
81, 2
160
96
48,46
186
ApPENDIX
237
Page
Anatomic Reference
Lateral pterygoid
Latissimus dorsi
Levator ani
Levator cestaTum
LevatOr scapula
Longus capitis
Longus colli
Lumbricals (foor)
Masseter
Maxilla (bone)
Medial collateral ligament
Medial pterygoid
Metacorpophalangeal joints
Metatarsal (bones)
Multifidus,cervical
Multifidus,lumbar
Multifidus,thoracic
Nasal bones
Navicular (bone)
Obliquus capitis superior
ObruramT extemus
Occipital bone
Occipimmasroid suture
Opponens pollicis
Palmar interossei
Patellar retinaculum
Patellar tendon
Pectineus
Pectoralis major
Pectoralis minor
Peroneus
Peroneus tertius
Piriformis
Plantar calcaneocuboid ligament
Plantar calcaneonavicular ligament
Plantar cuneonavicular ligament
Popliteus
Posterior cruciate ligament
PronatOr teres
Psoas
Pubococcygeus
Quadratus femoris
Quadratus lumborum
52
LPT
LD
117
PSI-5
175
PC8, PRI-12
83,101
120
MSC
6
AC3-5
67,74
AC2-6, AMC
218
PMT2,3
53
MAS
54
MAX
185
MK
51
MPT
139,140
PIN,DIN
214,217
DMT,PMT
81
PC3-7
160, 162,163,164
P L l -5,PL3,PL4-1,UPL5
96
PTI-12
55,56
NAS,SO
210,211
DNV,PNV
PCI-E
79
157
LPB
46,48
OCC,LAM
45
OM
138
CMI
139
PIN
183
PAT
184
PTE
157
LPB
115
PMA
116
PMI
195,202
LAN, PER
216
DMT4,5
171
PRM,PRL
209
PCB
211
PNV
213
PCN
192
POP
191
PCL
130
RHP
89,146
ATIO-12,ABLZ
180,ISS
COX,SPB
170
GEM
ATI2, QL, PL3-I, PL4-1, PT IO-12,UPL5,
89,161,162,163,99,164,103
PRI I ,12
207
PCA
183,184
PAT,PTE
66,78
ACI,PCI-F
75
LCI
PC2
80
120
MSC
81
PC3-7
160,162, 163, 164
PLI-5, PL3,PL4-1,UPL5
96
P T I-12
164,165
UPL5,LPL5
Quadratus plantae
Quadriceps femoris
Rectus capitis anterior
Rectus capitis lareralis
Rectus capitis posterior
Rhomboid
Rotatores, cervical
Rotatores,lumbar
Rotatores,thoracic
Sacroiliac ligaments
2,8
ApPENDIX
Anatomic Reference
Sacrospinolls ligament
Sacrotuberous ligament
Sagirtal suture
Sartorius
Scalenus anterior
Scalenus medius
Scalenus posterior
Serratus anterior
Soleus
Sphenobasilar suture
Sternocleidomastoid
Sternothyroid
Stylohyoid
Subclavius
Subscapularis
Supinator
Supraspinatus
Talocalcaneal joint
Talofibular ligament
Talonavicular ligament
Temporalis
Temporomandibular jOint
Temporoparietal joint
Tensor fascia law
Tentorium cerehclli
Teres major
Teres minor
Tibialis anterior
TIbialis posterior
Transversus [horae is
Trapezius
Triceps
Wrist extensors
Wrist flexors
Zygomatic bone
cox
COX,ISI
SAG
SAR
AC46
LC26, ARI
AR2,PRI
SER
PAN
PSB, LSB
AC7
ATI
SH
SCL
SUB
RHS
SSM,SSL
MCA, LCA, PCA
LAN
DNV
MAS, AT, PT
00, MPT, LPT, MAS, MAX
TPA,TPP
TFL
OM
TMA
TMI
TAL,TBA
TBP
MR3IO
TRA
LOL,MOL
DWR
PWR
AT,PT
Page
180
180,169
58
153
69
76,91
92,101
112
198
47, 59
72
86
49
107
I II
129
119, 109
205,206, 207
195
210
53,60,61
50,51,52,53,54
62,63
154
45
124
125
197,201
199
94
\06
132
137
136
60,61
239
ApPENDIX
Page
146
158
108
190
73
88
89
70
149
87
66
145
91
86
69
14
87
153
152
88
67
147
92
86
72
88
71
87
89
68
148
86
93
89
109
180
58
209
208
216
214
215
IJ7
101
102
198
140
138
196
207
199
240
ApPENDIX
Strain/Countmtrain Terminology
Page
Frontal (F)
Frozen Shoulder (F H)
Gluteus medius (GM)
Gluteus minimus (GMI)
High flareout 51 (HFO-SI)
High ilium-sacroiliac (HISI)
High navicular (H.NAV)
Iliacus (lL)
Infraorbital (10)
Inguinal ligament (lNG)
Inion
Interossei (lNT)
Interspace rib (4 Int-6 Int)
Lambdoid (L)
Lateral (1C)
Lateral ankle (LAN)
Lateral ankle (LAN)
Lateral calcaneus (LCA)
Lateral canthus (LC)
Lateral epicondyle (LEP)
Lateral hamstring (LH)
Lateral/medial coronoid (LCD/MCD)
Lateral meniscus (LM)
Lateral olecranon (LOL)
Lateral trochanter (LT)
Latissimus dorsi (LD)
Long head of biceps (LH)
Low ilium-flareout (LIFO)
Low ilium-sacroiliac (L1SI)
Lower pole fifth lumbar (LP5L)
LTS2
Masseter (M)
Medial ankle (MAN)
Medial ankle (MAN)
Medial calcaneus (MCA)
Medial coracoid (MC)
Medial epicondyle (MEP)
Medial hamstring (MH)
Medial meniscus (MM)
Medial olecranon (MOL)
Metatarsal
Midpole sacroiliac (MPSI)
MTS2
Nasal (N)
Navicular (NAV)
Occipitomastoid (OM)
Patella (PAT)
Patellar tendon (PTE)
Pes anserinus (PES)
Piriformis (PIR)
Point on spine (POS)
Posterior acromioclavicular (PAC)
Posterior auricular (PA)
Posterior cruciate ligament (PCR)
Frontal (FR)*
Medial humerus (MHU)*
Gluteus medius (GME)*
Tensor fascia lata (TFL)*
Inferior sacroiliac (151)*
Superior sacroiliac ( 5 1)*
Dorsal navicular (DNV)*
Iliacus (lL)
Maxilla (MAX)*
Lateral pubis (LPB)*
Posterior first cervical. flexion (PCI-F)*
Palmar interossei (PIN)*
Medial third to tenth rib (MRJ-IO)*
Lambda (LAM)*
Lateral first cervical (LCI)
Lateral ankle (LAN)
Peroneus (PER)*
Lateral calcaneus (LCA)
Anterior temporalis (AT)*
Lateral epicondyle (LEP)
Lateral hamstring (LH)
Lateral/medial coronoid (LCD/MCD)
Lateral knee (LK)*
Lateral olecranon (LOL)
Iliotibial band (lTB)*
Latissimus dorsi (LD)
Biceps long head (BLH)*
Inferior pubis (lPB)*
Superior pubis (SPB)*
Lower posterior fifth lumbar (LPL5)*
Infraspinatus superior (1 5 5)*
Masseter (MA )*
Medial ankle (MAN)
Tibialis anterior (TBA)*
Medial calcaneus (M A)
Pectoralis minor (PMI)*
Medial epicondyle (MEP)
Medial hamstring (MH)
Medial knee (MK)*
Medial olecranon (MOL)
Plantar metatarsal (PMTl-5)*
Middle sacroiliac (MSI)*
Medial scapula (MSC)**
Na al (NAS)*
Plantar navicular (PNV)*
Occipitomastoid (OM)
Patella (PAT)
Patellar tendon (PTE)
Pes anserinus (PES)
Piriformis medial (PRM)*
Infraspinatus middle (lSM)*
Posterior acromioclavicular (PAC)
Temporoparietal. post. (TPP)*
Posterior cTuciate ligament (PeL)
57
113
I7Z
154
169
167
210
151
54
157
78
139
94
48
75
195
202
206
60
127
18
131
186
132
173
117
110
156
155
165
III
53
194
ZOI
205
116
128
187
185
l3Z
217
168
120
55
211
45
183
184
189
171
122
liB
63
191
ApPENDIX
Strain/Counterstrain Terminology
*Change In tennmoIOb'Y_
241
Page
83
82
79
160
96
82
163
170
46
175
176
177
178
179
80
98
99
81
162
97
171
130
129
114
47
59
62
49
107
III
56
119
197
124
125
74
123
164
136
61
242
ApPENDIX
PRT Terminology
Page
Anterior cervicals
AC
65-74
LC
75,76
ATI
86
PRI
101
AR2
92
Pectoralis minor
PMI
116
Subscapularis
SUB
III
LD
117
AR3
93
Biceps
BLH, BSH
110,114
Lower Quadrant
The muscles of the lower quadrant, which, when tceated with strain and coumerstrain tech
niques, (or PRT) most efficiently affect spasticity. are as follows:
SCS Terminology
PRT Terminology
Page
PSI-PS5 COX
175-180
Quadratus lumborum
QL
161
Iliacus
IL
151
Piriformis
PRM,PRL
171
Adductor
ADD
158
Medial hamstrings
MH
187
Quadriceps
PAT
183
PAN
198
Medial ankle
MAN
194
Flexed calcaneus
PCA
207
Medial calcaneus
MCA
205
Talus
TAL
197
ApPENDIX
243
I I PATHOKINESIOLOGIC MODEl
EXAMPLES
I.
2.
3.
4.
5.
6.
7.
8.
9.
10.
II.
12.
13.
14.
IS.
I f the patient has a protracted shoulder girdle and there is a limitation in hori
zontal abduction, it is assumed that the pectoralis minor is hypertonic with short'
ened and contracted muscle fibers. The technique of a second depressed rib would
be utilized to decrease the gamma gain of the pectoralis minor.
I f the patient has an anteriorly displaced humeral head with an internally rotated
shoulder joint and limitation in external rotation, the technique for subscapularis
would be utilized.
If the patient has a limitation in shoulder abduction and a depressed humeral he," or
a caudal subluxation/dislocation of the glenohumeral joint, the techniques for the
latissimus dorsi and the third depressed rib would be utilized.
If the patient has an elevated shoulder girdle and there is a limitation 10 cervIcal
side bending to the opposite side, the lateral cervical techniques would be utili zed,
to decrease the gamma gain for the medial scalenes, which elevate the first rib.
If the proximal head of the first rib is elevated, rib excursion with respiration is inhlb,
ired. and lower cervical range of motion-especially rotation-is limited, the tech,
nique for an elevated first rib {PRO can be utilized.
I f the patient has a flexed elbow joint and a limitation in elbow extension, the
technique for the biceps can be utilized.
If the patient has a pronated forearm and a limitation of forearm supination, the
pomts for the medial epicondyle can be utilized. Often the proximal radial head is
displaced anterior, as a compensatory movement. The technIque for the rodial head
(RHS, RHP) can be utilized.
If the patient has an elevated pelvic girdle with a limitation of lumbar side bending
to the opposite side, the technique for the quadratus lumborum (the anterior
twelfth thoracic tender point) can be utilized.
If the patient has a hip flexion tightness or contracture with a limitation of hip exten#
sion, the technique for the iliacus can be utilized.
If the patient has an adducted and internally rotated hip and there is a limitation
of external rotation of the hip, the technique for the adductor can be utilized.
If the patient has a flexion synergic pattern of spasticity at the knee and there IS a
limitation of knee extension, the point for the medial hamstrmgs can be utilized.
If the patient has an extensor synergic pattern of spasticity at the knee with a Iimlta#
tion of flexion, the technique for the quadriceps (patella extenso,,) can be utilIZed.
If the patient has an equinus posture with a plantar flexed foot and a limitation in
dorsiflexion, the technique for the medial gastrocnemius (PAN) can be utilized.
If the patient has an equinovarus foot posture with a limitation in eversion. the
technique for the medial ankle and medial calcaneus can be utilized.
If the patient has a clubfoot with an internal rotated and dropped talus, the tech
nique for [he talus can be utilized.
244
ApPENDIX
Most of us view the skeleton as rhe frame upon which the soft tissues are draped. The POS[
andbeam construction of a skyscraper is the favored model for the spinel! and is used for all
biologic structures-the upright spine is regarded as the highest biomechanical achievement.
The soft tissues are regarded as stabilizing "guy wires," similar to the curtain walls of steel
framed buildings (Fig. I).
Skyscrapers are immobile, rigidly hinged, high-energy--consuming, vertically oriented
structures that depend on gravity to hold them together. The mechanical properties are New
tonian, Hookian, and Iinear.4.S A skyscraper's flagpole or any weight that cantilevers off the
building creates a bending moment in the column that produces instability. The building
must be rigid to withstand even the weight of a flag blowing in the wind. The heavier or far;
ther Out the cantilever, the stronger and more rigid the column must be (Fig. 2). A rigid
column requires a heavy base to support the incumbent load. The weight of the structure pro;
duces internal shear forces that are destabilizing and require energy just to keep the structure
intact (Fig. 3).
0.9 Meters
11
FIG. 2
(Above, left).
[J
[J
(Above, right). \Vhen simple coml}Tessitle load is apt>lied, bofh coml}Tessive wui shear smsses 1fI1L'if
cxist on t>/anes that are oriemed obliquely fO fhe line of application to fhe load..
FIG, 3
No.
2 May 1995
.
ApPENDIX
245
FIG. 6.
Bird
Skeleton.
""
FIG. 5.
.......... ,"
FIG. 7.
""
"'"
frame.
246
ApPENDIX
and D,
creates leverage. There are no levers in a truss, and the load is distributed throughout the
structure. A truss is fully triangulated, inherently stable, and cannot be bem without pro
dueing large deformations of individual members. Since only trusses are inherently stable
with freely moving hinges,it follows that any stable structure with freely moving hinges must
be a truss. Vertebrates with flexible joints must therefore be constructed as tfusses.
When the tension elements of a truss 8rc wires or ropes, the truss usually becomes uni#
diredtional (see Fig. 7); the element that is under tension will be under compression when
turned topsy[Urvy. The tension elementS of the body (the soft tissues-fascia, muscles,liga;
ments,and connective tissue) have largely been ignored as construction members of rhe body
frame and have been viewed only as the motors. In loading a truss the elements rhat are in
tension can be replaced by flexible materials such as ropes,wires, or in biologic systems,liga
ments, muscles, and fascia. Therefore, the tension clements are an imegral part of rhe con
struction and not just a secondary support. However, ropes and soft tissue can only function
as tension elements, and most trusses constructed with tension members will only function
when oriented in one direction. They could not function as mobile, omnidirectional struc;
rures necessary for biologic functions. There is a class of trusses called censegrityJ structures
that are omnidirectional so that the tension elements always function in tension regardless of
the direction of applied force. A wire bicycle wheel is a familiar example of a tensegrity struc
ture. The compression elements in tensegrity structures "float" in a tension network JUSt as
the hub of a wire wheel is suspended in a tension network of spokes.
To conceive of an evolutionary system construction of tensegrity trusses that can be used
to model biologic organisms, we must find a tensegriry truss that can be linked in a hierar
chical construction. It must start at the smallest subcellular component and must have the
potential, like the beehive, to build itself. The structure would be an integrated tensegrity
truss that evolved from infinitely smaller trusses that could be, like the beehive cell, both
structurally independent and interdependent at the same time. This repetion of forms,like in
a hologram, helps in visualizing the evolutionary progression of complex forms from simple
ones. This holographic concept seems to apply to the truss model as well.
Architect Buckminster FullerJ and sculptor Kenneth Snelsonu described the truss that fits
these requirements,the tensegrity icosahedron. In this structure,the outer shell is under tcn
sian, and the vertices are held apart by internal compression !istrutS" that seem to float in the
tension network (Fig. 8).
The tensegrity icosahedron is a naturally occurring, fully triangulated, three-dimensional
truss. It is an omnidirectional, gravity-independent, flexibly hinged structure whose mechan
ical behavior is nonlinear, non-Newtonian, and non-Hookian. Independently, Fuller and
ApPENDIX
FIG. 9.
FIG. 1 0.
247
Snelson use this truss [0 build complex structures. Fuller's familiar geodesic dome is an
example, and Snelson 12 has used it for artistic sculptures that can be seen around the world.
Ingber7.16 and colleagues use the icosahedron for modeling cell construction. Research is
underway [Q use this structure in more complex tissue modeling, 16 Naturally occurring exam#
pies that have already been recognized as icosahedra arc the selfgenera[ing fullerenes
(carbon 0 organic molecules),S viruses,17 clemrins,' cells, IS radiolari3,6 pollen grains, dandelion
6
balls. blowfish. and several other biologic structures (Fig. 9).
Icosahedra are stable even with frictionless hinges and, at the same time, can easily be
altered in shape or stiffness merely by shortening or lengthening one or several tension ele
ments. Icosahedra can be linked in an infinite variety of sizes or shapes in a modular or hierar
chical pattern with the tension elemems (the muscles, ligaments, and fascia) forming a con
tinuous interconnecting network and with the compression elements {the bones} suspended
within that network (Fig. to). The structure would always maintain the characteristics of a
single icosahedron. A shaft, such as a spine, may be built that is omnidirectional and can fune..
rion equally well in tension or compression with the intemal stresses always distributed in
tension or compression. Because there are no bending moments within a tensegrity structure,
they have the lowest energy COSts.
248
ApPENDIX
f'iiCt
___ shoulder
humerus
ulna
/'
elbow
radius
Fig. I I .
lco.ro arm.
FIG. 1 2.
Viewed as a model for the spine of human:, or nny vertehrate :-,pecics, the tl'llsion Icoahe#
lIron space truss (Fig. II) with the hones acting
ilS
MIl'S as the tenSIOn elements will be swble in <lny position, even With muluple Joint.... They
can be vertical or horizontal ami assume any posture from ramrod slraight [() a !oiigmllid curve
(Fig. 12). Shortening one soft tissue element has a Tlpplmg effect throughout rhe structure.
Movement IS crc<.Ucu and a new, Instantly stahle shape IS achicvcu. It IS highly mohile, (lmrll
directional, and consumes low energy. TenSIOn icosahedrons arc unique S[fUelures who!'.c con
MTtlctS, when used a a hiologlc model, would conform t() the nawral law!'. of Icast energy, law"!
of mechanic!<!, and the distinct characteristics llf hioll)glc tISUCS. The icosahedron space trus
is present in biologic struc[Ure at the cellular, subcellular, and multicellular Icvcl.... Recent
research on the molecular structures of organisms such as Vlfuses, subcellular org.mel lcs, md
whole orgarHsms has shown them to be Icosahedra. The very hudding block o( lXlIlC, hydroxy
apatite, is an icosahedron. In the spine, each subsystem ( vertebrae, dbks, sort tissues) would
be suhsystems of the spme metasystem. Each would function as ;.In Icosahedron IIldepcndcntly
and as part of the larger system, as in the beehive analogy.
The icosahedron space tru spmc model is a universal, illl:xiuhu, hicmrdHcal ystCill that
has the widest application with the least energy cost. As the simplest <lnd least cnergy-cnn
suming system, It becomes the metasystem to which a l l other systems and suhsystem!'. must he
judged and, if they are not simpler, more adaptable, and less energy con!'.Ullllllg, rejected.
Smce this system always works With thc least energy requirement'l, there would he no benefit
to nature for spines to function sometimes as a post, sometimes as a hearn, sometimes a"i a tnl"iS,
or to function thfferenrly for dif(erenr species, conformmg to the minimal IIwcnrory-m..lx#
imum diverSity concept of Pearce10 and evolutionary theory.
The Icosahedron space truss model could be extended to lI'lCorpOT'cltc other ilnatOlniC and
physiologic systems. For example, as a "pump" the icoaheJron functions rem<lTkahly like Glr#
diac and respiratory models, and,
so,
ApPENDIX
249
References
1.
2.
J.
4.
5.
6.
7.
8.
9.
10.
I I.
12.
13.
14.
15.
16.
17.
de Dlive C: A Guided Tour of the LIving Cell. Vol. 1. New York, Sciemific Books. 1984.
Fieldmg Wj. Burstem AH, Fr::mkel VH: The nuchal ligament. Spme 1:314, 1976.
Fuller, RB: Syncrgcllcs. New York, Macmillan, 1975.
Gordon. JE: Structures or Why Things Don't Fall Down. New York, Dc C'lpa Press, 1978.
Gordon, JE: The Science of Structures and Marcri;lls. New York. Scientific American library, 1988.
Hacckel E: Report on the scientific result:. of the voyage of [he H.M.S. Challenger. Vol 18. pt XL. Radio
lana, Edinburgh, 1887.
Ingber DE, Jamieson J : Cells as rcnsegriry Sfructures. Architectural regulation of hisrodiffercmiation by phys
ical (orces transduced over basement membrane. In Andersonn LL, Gahmberg eG. Kblom PE (cds): Gene
Expression Dunng Normal and Malignant Differentiation. New York, Academic Press, 1985, pp 1 330.
Ktoto H: Space, smfS, C6Cl, and soot. Science 242: 1 1 391 145, 1988.
levin SM: The icosahedron as {he three-dimensional finite clement in bio-mechanical support. Procccdmg
of the Society of General S's(ems Research Symposium on Mental Images, Values and Reality, Philadelphia,
1986. St. Louis, Society of General Systems Research. 1986, pp G 14-G26.
Pearce PL: Structure in Nature as a Strategy for DeSign. C1mbridgc. MA, MIT Press, 1978.
Schultz AB: Biomechanics of the spine. In Nelson L (ed): Low Back Pain and Industrial and Social Disable
ment. London, American Back Pain Association, 1983, pp 20-25.
Schult! DO, Fox HN: Kenneth Snelson, Albnght-Knox Art Gallery (catalogue), Buffalo. 1 98 1 .
Snelson KD: Continuous tension, dlscontmuous compression structures. U.S. Patent 3 , 1 69,6 1 1 . Washington.
OC, U.S. Patem Office, 1965.
Thompson D: On Growth and Fonn. Cambridge, Cambridge UmvcrsllY Press, 1961.
Wnng N, Butler JP. Ingber DE: Microtranuction across the cell surface and through the cytoskeleton. Sci
ence 260, 1 1 2 4- 1 1 27. 1993.
Wendling S: Personal communication. L1boratory of Physical Mcchalllcs, Faculty of Science and
Technology, Paris.
Wildy P, Home RW: Srructure of animal Virus particles. Prog Med Virol 5: 1 -42, 1963.
250
ApPENDIX
This table was specifically designed to reduce practitioner strain and facilitate the practice of PRT. It is available through
Hill Laboratories' in Frazer Pennsylvania. A few of the features and possible applications are listed below.
Multi#scctional
Mocorized elevation 22" to 3Sn
. iI
'
- ./
-_
..
- -
Anterior/posterior cervical
Rib treatment
Posterior thoracic
Posterior lumbar
Anterior lumbar/thoracic
lliacu
----'
[;II LabornlOdes Co., 3 Bacton H;II Rd., F""e<. Penn., 1 9355 , (6 1 0) 644-2867.
G lossary
active myofascial trigger point: A focus of hyperirri
tability in a muscle or its fascia. An active trigger point is
always tender, prevents full lengthening of the muscle,
weakens the muscle. usually refers pain on direct com
pression, mediates a local response of muscle fibers when
adequately stimulated, and often produces specific
referred autonomic phenomena. generally in its pain
reference zone.
acute somatic dysfunction: Immediate or short-term
impairment or altered function of related components
of the somatic (body framework) system. Characterized
in early stages by vasodilation, edema, tenderness, pain,
and contraction.
adaptation: The process of attaining homeostasis with
respect to changing internal or external circumstances.
Adaptation uses the capability of the organism to operate
efficiently under altered conditions.
anatomic barrier: The limit of motion imposed by
anatomic structure.
articular strain: The result of forces acting on a joint
beyond its capacity to adapt. Refers to stretching of joint
components beyond physiologic limits, causing damage.
barrier (motion barrier): limit of unimpeded motion.
biomechanics: The application of mechanical laws to
living structures. The study and knowledge of biologic
function from an application of mechanical principles.
chiropractic: The science of treating human ailments by
manipulation and adjustment of the spine and other struc
tures of the human body. The uses of such other mechan
ical, physiotherapeutic, dietetic, hygienic, and sanitary mea
sure. except drugs and major surgery, as are incident to
the care of the human body.
chronic somatic dysfunction: Long-standing impair
ment or altered function of related components of the
somatic (body framework) system. Characterized by ten
derness. itching. fibrosis. paresthesias. and contracture.
comfort zone: The optimal position of ease. It is a posi
tion where there is no tenderness and the tissues are
completely released. Also called a position of comfort
compensation: Counterbalancing or making up for a
defect in structure or function in the body. It may employ
mechanisms that meet the definition of adaptation. but it
more likely implies adjustment at the expense of efficiency
and with greater likelihood of fatigue and wear and tear.
Both functional and anatomic breakdown are more likely
to occur in a compensated situation
counterstrain technique: An indirect technique devel
oped by Lawrence Jones, D.O.The operator moves the
patient or part passively away from the motion barrier
toward and into the planes of increased motion. always
252
GLOSSARY
GLOSSARY
253
Index
see
posterior, 105, I 1 8
pain, 1 43 ;
Acupuncture poims, 2 , 3 ;
see
also Ah
see
also Pain
also
Bioenergetic exercises, I , 2;
see
Exercises
also
133, 1 34
Core swhdi:auon, I
c
Calcaneus tender points
lateral, 204, 206
lateral, 1 93 , 195
Annulospiral endings, I I , I I , 1 2
Arachidonic acid, 1 2
Arm;
see
palpation of, 2 2 1
Common cxtcn:.or tcndon tender
Common flexor tendon tender point,
point, 1 3 3 , /35
postures
anterior, 193, 1 96
tibialis, anterior, 1 93 , 20 I
second, 77, 80
third, 77, 8 1
Coccyx tender poinl, 174, 180
treating, 4 3
ralus, 1 93 , 197
first, 77-79
Chapman's reflexc, 4
Birth injuries
1 14
dysfunction 0(, 1 8 1
75-76
first, 65, 75
eighth, 77, 83
1 10
Bone [issue, 8, 9
203
Back;
landmarks (or, 64
Cranium
dysfunction of, 4 3
tender poinrs 0(, 4 3 , 44-63
digastric, 44, 50
(mnt"l, 44, 57
lambda, 44, 48
masseter, 44 , 53
maxilla, 44, 54
eighth, 65, 73
nasal, 44, 55
fifth, 65, 70
occipital, 44, 46
Asymmetry
first, 65, 66
OCCipitomastoid. 44, 45
postural, 40
(ourth, 65, 69
medial, 65, 74
second, 65, 67
seventh, 65, 72
sixth, 65, 71
third, 65, 68
stylohyoid, 44, 49
dysfunction of, 64
slJpraorbi,"I, 44, 56
255
256
INDEX
tcmrorah,anterior, 44. 60
tcmrorall, posterior, 44. 6 1
temporoparietal anterior,44, 62
temporoparietal r()(erior. 44, 63
Cn)S..reference charts
for anatomy and positional release
therapy, 236-238
for stmm/countcrstr;'llll and pOSI
tional release therapy,
239-241
Cruciarc ligament tender pmnts
anten"" 182, 190
pO>len"" 182, 1 9 1
CubniJ render points
dorsal,204 , 208
plantar, 204, 209
Cumul.ulvc trauma lhsordcr. 224; see
also Repetitive stram Injury
Cuneiform tender pOints
Jor"'ll
first through third,204, 2 1 2
plantar
firS[ lhrough t1md,204, 2 1 3
Cupules,2
epIcondyle, medial, 1 26 , 1 28
olecranon, lateral/medIal, 126,
132
Devices
,"Slstive,22 1, 250
Diagnosis; see also Scannmg
evaluation
funcuonal. 3
protocol for, 40
Digastric tender point. 44, 50
Direct [cchni4ue. 2; see also Indirect
technique
Dominant tender POInt,27. 40; see
abo Tender pOlllt:-.
III '\C,mnmg evaluation, 3637
Dynamic neutral position, 3
DynamIC recIprocal balance, 3
DY(lInction; see also Mlisculokeletal
JY(lInction; Somatic Jysfunc
lion; specific anatomic areas
global,27
E
Elhow
dyfunction of,104
tender pOints of, 104, 126-132
coronOId, lateral/medial, 1 26 , 1 3 1
epIcondyle, lateral, 1 26, 1 27
193, 200
G
Gamma bias, II
Gamma effercnt neurons, I I
Gemellt tenJer POlnl, 166, 1 70
Gcriatric patients
treatmg, 23
Global dysfunction,27; see also Mus
culoskelctal dysfunction;
Somauc dys(ucnllon; specific
anatomic areas
Global treatment,
vs. local treatmem,27, 27
Glossary, 251-25 3
Glutcus medlu tender [XHnt, 166,
172
H
Hamstring render POlllts
lateral, 182, 188
medIal, 182, 187
Hand/WrISt
dysfunction of, 104
tender pOints of, 104, 133- 1 4 1
carpometacarpal,first, 1 3 3 , 138
common flexor tendon, 133
I
134
WrI,t, dorsal, 1 3 3 , 1 3 7
WrISt, palmar, 1 3 3 , 136
Head; see Cranium
INDEX
Highgain servomechanism, I I
Hip/pelvis
anterior tender points oC 1 4 3 ,
150-158
iliacus, ISO, 1 5 1
Knee
gemelli, 1 66 , 1 70
gluteus medius, 1 66 , 1 72
upper fifth, 1 5 9 , 1 64
1 66-173
1 5 9- 1 65
152
pubis, inferior, ISO, 156
dy,function of, 1 43
third-iliac, 159, 1 62
dysfunction of, 1 4 3
dysfunction of, 1 8 1
Mechanoreceptors. 1 0
Metatarsal tender points
182, 190
cruciate I igament, posterior,
dorsal, 204, 2 1 4- 2 1 6
first, 204, 2 1 4
182, 1 9 1
171
plantar, 204, 2 1 7- 2 1 9
fifth, 204, 2 1 9
sacroiliac, middle, 1 66 , 1 68
first, 204, 2 1 7
sacroliac, superior, 1 66 , 1 67
Humerus tender pain[
medial, lOS, 1 1 3
1 73
o(l1lotion assessment
normalization of, 20
joint, 20
Hypomobility
protective, 1 9
Muscle spindles, I I , 1 I
Musculoskeletal dysfunction, 7,
1 17
Legs; see Ankle; Knee
Lesion; see Facilitated segments;
Injury
limbs; see Lower limb; Upper limb
Lower body
Inflammation
Myofa!lcial [issue, 1 0
anatomic areas
Lower limb
dysfunction of, 1 8 1
tender points of, 2 3 , 1 8 1 , 182-
middle, lOS, 1 22
superior, 105 , I 2 1
areas
Injury
mOtor vehicle, 2 3
tissue, 8- 10, 1 2
Interosseous tender points
Lumbar spine
anterior tender points of, 1 43 ,
144-149
abdominal second, 144, 146
dorsal, 1 33 , 140
fifth, 1 44 , 149
palmar, 1 33 , 139
first, 144, 1 45
I nterphalangeal joints
tender points of, 133, 1 4 1
Intrafusal fibers, I I , 1 1
257
dorsal, 204, 2 1 0
plantar, 204, 2 1 1
Neck; see Cervical spine
Neurologic pa[ients
treating, 24, 242
Neurolymphatic points, 9; see also
second, 144, 1 47
third, 2 2 3
poin[s
INDEX
258
Neurovascular poin[. 9;
see also
optimal, 30
points
NocicepmTs, 1 0
i n somatic dysfunction, 1 2 1 3
Nonlinear process
of positional release therapy, 8
Position of treatment;
see
Position of
1 26, 1 29
Ohesity
considerations in treatment, 2 2 3
Range,oflllQ(ion assessment, 40
lateral/medial, 1 26 , 1 3 2
O'teopathic positioning table, 250
Osteoporosis
treatment 0(, 23
p
Plin
origins of, 1 5
first, 90, 9 1
second, 90, 92
184
Pathokinesiologic determination
2 2 2 2 2 3 , 225
forms for, 232233
tender poims in;
amputee, 24
see
Tender points
treatment
phases of, 2 1 22
plan, 3 1 3 3, 3738, 40
treating, 24
Rib cage
224
dysfunction of, 84
back, 1 4 3
posttreatmCrH, 225
poims
homebased, 2 2 5
1 26, 130
Radial head supinator tender point,
principles of, 29
procedures, 3940;
anatomic areas
geriatric, 2 3
inferior, 1 66 , 169
225
neurologic, 242
superior, 1 66 , 167
obese, 223
Postural asymmetry, 40
pediatric. 23
Posture, I ;
Yoga postures
respiratory, 24
Sacrulll
posterior tender points of, 1 4 3 ,
1 74180
coccyx, 174, 180
Proprioceptors, 1 0 1 2
fifth, 1 74 , 179
first, 1 74 , 1 75
Pediatric patients
PRT;
neating, 2 3
Pelvis;
see Hip/pelvis
fourth, 1 74 , 1 78
second, 1 74 , 1 76
third, 1 74, 1 77
Sagittal suture tender point, 44, 58
SartOrius render points, 150, 153
Scanning evaluation, 3538
medial, 1 66, 1 7 1
lateral, 166, 1 7 1
procedure for, 5
INDEX
Scapula tender point
medial, 105, 1 20
erratus anterior tender point, 1 05 ,
1 12
III
high-gain, I I
medial, 105, 1 1 9
acromioclavicular, anterior, 1 05 ,
108
humerus, medial, 1 05 , 1 1 3
95-99
Tibialis
anterior, 44, 62
myofascial, 1 0
posterior, 44, 63
scapula, medial, 1 05 , 1 20
points
pectoralis major, 1 05 , 1 1 5
dysfunction of, 84
1 18
Shoulder
Servomechanism
subscapularis, 105, I I I
conflicting, 2 2 3
dominant, 27, 40
history of, 2
anatomic areas
anaromic areas
in musculoskeletal dysfunction,
9- 1 0
Smai, I
Sphenobasilar tender point
lateral, 44, 59
Spine; see Cervical spine; Lumbar
spine; Thoracic spine
Sports injuries
treating, 23-24
Sternocleidomastoid muscle, 23
loskeletal dysfunction
treating, 229
treating, 2 3
palpating, 28
259
Tensegrity
in lower limb dysfunction, 1 8 1
model, 8, 1 4- 1 5, 228, 246-248,
247
Tension
fascial; see Fascial tension
u
Upper body
evaluation form for, 4 1
treatment of, 22-23; lee also specific
anatomic areas
Upper limb
dysfunction of, 104
tender points of, 22-23, 104,
1 05 - 1 4 1 ; see also specific
anatomic areas
icosohedron, 1 4- 1 5
Tensor fascia lata tender point, 150,
154
Teres major tender point, 1 05 , 1 24
Teres minor tender point, /OS, 1 25
w
Wrist; see Hand/wrist
Thoracic spine
anterior tender points of, 84,
85- 9
Yoga postures, I , 1